HX641 33095 
RC311  .Z65  1888    Pulmonary  tuberculos 

1838 


RECAP 


Ziemssen 

•••Pulmonary  tuberculosis 


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'aid  TH£K...  ,  ^.. 


PEPTONISED  MILK. 

(FAIRCHILD     PROCESS.) 

The  Ideal  Food  for  the  sick,  the  delicate,  the  con- 
sumptive, the  habitual  dyspeptic,  the  diabetic. 


Peptonised  Milk  is  milk  in  which  the 
caseine  has  been  wholly  or  partially 
converted  into  peptone,  the  degree  of 
this  conversion  to  be  controlled  at  will, 
as  determined  by  the  needs  of  the  case. 
AH  the  other  elements  of  the  milk,  the 
sugar,  fat  and  mineral  salts,  are  already 
provided  by  nature  in  a  condition  for 
perfect  assimilation,  without  digestive 
effort. 

One  pint  of  Milk,  when  peptonised, 
contains  two  oitoces  of  total  dry 
SOLIDS— MrLK  Peptones,  Milk  Suoau, 
Fat  and  Ash. 

Of  Beef  Tea,  Dr.  Christison  says: 
"He  was  able  to  obtain  but  a  quarter 
"of  an  ounce  of  solid  residue  in  a 
"pint.'''' 

This  solid  residue  consists  of  "  besides 
'*  the  trifling  amount  of  proteid  mater- 
"ial  and  of  fat  (which  latter,  in  prac- 
"  tice,  is  guarded  against  with  great 
*'  care),  only  the  salts  of  the  muscle,  the 
"liematin,  and  (dlied  pigments,  traces 
"of  sugar,  perhaps,  some  lactic  acid, 
"  and  the  nitrogenous  extractives  crea- 
"  tin  and  its  congeners.  As  the  original 
"half  pound  of  muscle  may  cont^n 
"about   forty   to   sixty  grains  of  the 


"salts,  and  ten  to  twelve  grains  of  the 
"  nitrogenous  waste  products,  the  beef 
"  tea  (half  pint)  certainly  contained  no 
"more."— Prof.  Bauugarten. 

Of  Beef  Extract,  Dr.  Pavy  says: 
"There  are  grounds  for  believing  that 
"a  considerable  proportion  consists  of 
"  products  of  proteid  decay,  materials 
"in  course  of  retrograde  metamorpho- 
"  sis,  that  are  of  no  use  as  nutritive 
"agents." 

The  well  nigh  superstitious  ideas  en- 
tertained by  the  laity  of  beef  tea,  is 
expressed  in  the  allusion  to  the 
"strength"  which  is  popularly  sup- 
posed to  be  extracted  in  the  tea;  after 
which  the  beef  is  thrown  to  the  dogs. 
The  working  man  makes  soup  from  a 
joint  and  consumes  the  "strength"  and 
the  beef  both . 

The  medical  profession  insist  that 
patients  shall  profit  by  the  knowledge 
and  progress  of  medical  science,  by  the 
use  of  artificially  digested  fresh  milk, 
etc.  The  Nostrum  advertisers  usurp 
functions  of  the  physician  by  prescrib- 
ing fictitious  "  foods  for  invalids,"  foods 
which  medical  science  has  long  since 
condemned. 


PEPTONISING   TUBES 

In  boxes  of  1  dozen  tubes,  at  50  cents  retail.     Each  tube  peptonises  one  pint  of 
milk. 

Pamphlets  and  samples  gratis  to  physicians. 


F:±IRCHILD  BROS.  <ft  FOSTER, 

82  8c  84  FULTON  STREET    NEW  YORK. 


i^m^mm^m^^m^^^^'^'^^^B^ 


I  »  *  NOTICE.  -•  « 

I      In  pursuance  of  recently  effected  and   mutually 

I  satisfactory   arrangements,   all    the    publications   of 

8  Geo.  S.  Davis,  Medical  Publisher,  will  hereafter  be  t 

I  issued  by  William  M.  Warren,  Medical  Publisher.  | 

jj  All  contracts  with  reference  to  such  publications,  of 

I  whatever  nature,  entered  into  with  Geo.  S.  Davis, 

I  Medical  Publisher,  will  be  fulfilled  by,  and  all  obli- 

jj  gations,  amounts  due,  etc.,  are  payable  to,  William 

1  M.  Warren,  Medical  Publisher. 


PULMDNARY    TUBERCULDSIS. 

ITS  ETIOLOGY,   SYMPTOMATOLOGY  AND 
THERAPEUTICS. 


PROF.  DR.  H.  VON  ZIEMSSEN, 

Director  of  the  Medical  Clinic  at  Munich. 


TRANSLATED    BY 


DAVID  J.   DOHERTY,  A.   M.,  M.  D. 

Instructor  in  the  Chicago  Policlinic. 


1888. 
GEORGE  S.   DAVIS. 

DETROIT.    MK;U. 


RC3/ 1 


Copyrighted  by 

GEORGE    S.    DAVIS. 

1888. 


PREFATORY  NOTE. 

This  little  work  on  Tuberculosis  contains  the  views  of 
one  of  the  most  eminent  clinical  teachers  and  practitioners 
in  Europe.  It  is,  I  think,  the  most  recent  published  utter- 
ance on  the  subject.  The  matter  was  delivered  in  the  form 
of  lectures  to  his  pupils  and  consequently  some  diffuseness 
and  repetitions  occur.  The  translation,  though  not  elegant, 
is  faithful. 

D.  J.  D. 
ToSute  St.,  and  143  North  Ave,  Chicago,  lU. 


TABLE10F  CONTENTS. 


PART  FIRST. 
ETIOLOGY. 

PAGE. 
CHAPTER  I.     The  Tubercle  Bacillus— Hereditary  Trans- 
mission— Direct  Infection i 

"         II.     Inherited  and  Acquired  Predisposition — 

Social  Foci 9 

"  III.  Invasion  of  the  Bacilli — Defence  of  the 
Organism — Vulnerability  of  the  Apex 
— Theory  of  Phagocytes — Invulner- 
ability of  the  Larynx 19 


PART  SECOND. 

DIAGNOSIS. 

CHAPTER  I.     Paralytic  Thorax— Apices 30 

"         II.     Sputum — Bacilli — Elastic  Fibres — Myelin 

Cells — Hemoptysis 43 

"        III.     Fever — Idiomuscular   Tumors  —  Contrac- 
tion Waves 52 

"        IV.     Spirometry — Weighing 60 


PART  THIRD. 

TREATMENT. 

CHAPTER  I.  Prophylactic— Hygiene— Choice  of  Em- 
ploytnent — Precautions  against  Con- 
tagion— Hydrotherapy 64 

"         n.     Direct — Hygienic  —  Climatic — Dietetic — 

Medicinal 94 

"  ni.  Secondary  Tuberculosis — Complications — 
Tuberculosis  of  Larynx — Tubercu- 
losis of  Intestines — Anal  Fistula....   109 

APPENDIX. 

A.  Tuberculosis  in  American  Prisons 114 

B.  Method  of  Examining  Sputum  for  Balilli 119 


PART  FIRST. 


THE  ETIOLOGY  OF  TUBERCULOSIS. 


CHAPTER  I. 

THE    TUBERCLE     BACILLUS— HEREDITARY 
TRANSMISSION— DIRECT  INFECTION. 

The  radical  revolution  produced  in  theories  con- 
cerning the  nature  of  tuberculosis  by  the  classical  re- 
searches of  Koch  has  also  had  a  reformatory  influence 
on  clinical  views.  So  long  as  the  nature  of  tuber- 
culosis was  unknown,  theory  drifted  hither  and  thither 
as  the  prevailing  current  carried  it.  At  one  time 
tabercle  was  held  to  be  a  neoplasm,  again  something 
specific  and  infectious,  again  a  product  of  inflamma- 
tion. Its  origin  from  bronchial  catarrh,  pulmonary 
hemorrhage,  pneumonia,  inhalation  of  dust,  etc.,  was 
asserted  and  denied  with  equal  vigor.  Its  contagious- 
ness was  at  times  maintained  and  at  other  times  rejected. 
Inheritance  alone  was  always  considered  to  be  an  un- 
assailable and  sure  etiological  factor;  but  lately  even 
that  has  not  escaped  question. 

Through    this  chaos  of   theory  and    empiricism, 


Koch's  discovery  suddenly  shot  a  piercing  ray  which 
not  only  illuminated  the  very  kernel  of  the  subject, 
but  spread  light  and  guidance  in  every  direction.  By 
a  single  stroke,  the  old  and  much  debated  knot  of  the 
nature  of  tuberculosis  was  untied,  and  the  parasitic 
character  both  of  it  and  of  scrofula  in  all  their  forms 
and  situations  was  established. 

I  remember  well  the  profound  impression  pro- 
duced upon  the  members  of  the  Pharmacopoeia  Com- 
mission by  the  first  demonstration  which  Koch  made 
in  the  laboratory  of  the  Imperial  Sanitary  Bureau.  He 
had  not  then  made  public  his  discovery;*  but  he 
graciously  yielded  to  our  desires  and  those  of  the  then 
chief  of  the  Sanitary  Bureau  (Dr.  Struck),  and  ex- 
plained to  us  his  preparations  and  the  manner  in 
which  he  had  made  the  discovery.  In  that  modest 
laboratory  of  the  unassuming  scholar,  we  saw  one  of 
the  greatest  puzzles  of  pathology,  the  nature  of  the 
worst  scourge  of  humanity,  unravelled.  And  how 
complete,  rounded  and  positive  his  solution  of  the 
problem  was  became  evident  when  criticism  and  sub- 
sequent investigation  found  not  only  nothing  import- 
ant to  change,  but  even  scarcely  anything  of  value  to 
add.  There  was  not  a  weak  link  in  the  entire  chain 
of  demonstration. 

Clinical  medicine  at  once  accepted  the  new  doc- 
trine and  frankly  interested  itself  in  the  reconstruction 

*He   announced   it   in   the  Berliner  Kliti.    JVochenschtift, 
1882,  No.  15.— Tr. 


of  views  which  it  imposed.  Every  intelHgent  person, 
however,  saw  clearly  that  there  would  be  many  diffi- 
culties in  the  beginning.  Various  points  in  the  sub- 
ject of  tuberculosis  seemed,  from  the  standpoint  of 
the  bacillus  theory,  to  be  beset  by  almost  insuperable 
difficulties.  Among  them  stood  at  the  very  threshold 
the  question  of  Inheritability. 

In  truth,  no  fact  of  experience  seems  so  firmly 
established  as  the  inheritability  of  tuberculosis.  Day 
after  day  the  physician  sees  this  disease  reap  its  harvest 
among  the  offspring  of  tuberculous  parents.  In  infancy 
scrofulous,  in  youth  tuberculous — that  is  the  history 
of  such  children  as  they  grow  up  and  wither  away. 
How  can  this  axiom  of  experience  be  made  to  har- 
monize with  the  bacillus  doctrine  of  Koch  ?  Various 
solutions  have  been  attempted.  Thus  far,  however, 
most  of  the  attempts  involve  hypotheses  which,  though 
supported  by  some  scattered  facts,  on  the  whole  lack 
demonstration. 

The  transmission  of  tuberculosis  on  the  side  of 
father  is  supposed  to  take  place  at  the  moment  of 
conception,  by  means  of  spermatozoa  which  contain 
bacilli.  In  behalf  of  this  explanation,  nothing  more 
is  presented  than  the  fact  that  bacilli  have  been  found 
in  the  testicles  of  tuberculous  men.  Transmission 
from  the  mother  at  the  time  of  conception  must  pre- 
suppose an  ovum  either  originally  infected  with  bacilli 
or  become  infected  during  its  passage.  Furthermore, 
there  is  the  possibility  of  a  later  intra-uterine  infection 


—  4  — 

of  the  child  by  the  paternal  seed  or  the  maternal 
blood.  These  hypotheses,  however,  are  only  desper- 
ate resources.  The  lack  of  direct  proof  of  hereditary 
transmission  has  stimulated  the  search  for  other  meth- 
ods of  accounting  for  family  tuberculosis.  S^e,  in  his 
work  on  Bacillary  Tuberculosis,  and  Riihle,  in  his 
paper  read  before  the  Sixth  Congress  of  Clinical 
Medicine  and  in  his  Treatise  on  Tuberculosis  (in  my 
Hand-book  of  Special  Pathology  and  Therapeutics), 
have  made  a  notable  effort  in  that  direction,  namely ,^ 
to  substitute  post-foetal  infection  for  intra-uterine. 
Such  an  effort  deserves  the  greatest  attention,  because 
much  more  can  be  done  to  liberate  mankind  from 
tuberculosis  if,  instead  of  heredity  which  is  difficult  to 
influence,  we  should  have  to  deal  with  extra-uterine 
infection,  the  sources  of  which  seem  more  easy  of 
recognition  and  control. 

Certainly  there  are  many  and  obvious  ways  in 
which  a  child  may  be  infected.  Close  contact  with  a 
diseased  mother  or  nurse,  the  kiss  of  a  tuberculous 
father,  contamination  of  food  with  tubercle  bacilli, 
bacillary  infection  of  wounds — all  these  are  sources  of 
infection,  and  their  power  is  proportioned  to  the 
weakness  of  the  infantile  organism.  Next  to  direct 
contagion  from  the  sick,  milk  containing  bacilli  or 
spores  is  the  most  likely  source  of  infection.  When 
we  consider  the  frequency  of  bovine  tuberculosis,  we 
must  see  how  great  the  danger  from  this  source  is, 
especially  if  the  milk  be  unmixed  and  exclusively  from 


a  sick  cow,  or  if  the  udder  of  the  animal  should  be 
tuberculous.  Food  experiments  lately  made  by  Bol- 
linger and  his  pupils  have  established  the  noteworthy 
fact  that  the  milk  of  tuberculous  cows  is  infectious  for 
Guinea-pigs,  even  when  the  udders  are  entirely 
healthy  and  the  cows,  though  afflicted  with  local  pul- 
monary or  pleuritic  tuberculosis,  are  in  the  best  condi- 
tion of  nourishment.  Of  course,  the  infectiousness  is 
much  diminished  by  the  customary  admixture  of  the 
milk  of  infected  cattle  with  that  of  healthy  ones;  and 
it  is  completely  destroyed  by  boiling  for  five  minutes. 
People,  however,  are  usually  negligent  concerning  a 
danger  which  they  do  not  see.  Even  in  intelligent 
families  too  little  attention  is  paid  to  the  source  of 
milk  supplied  to  nurslings,  and  the  regular  boiling  is 
often  done  without  due  care.  A  mother  who  relegates 
to  the  cook  the  task  of  preparing  the  baby's  milk  may 
be  pretty  sure  that  it  will  not  be  properly  done.  Phy- 
sicians should  impress  upon  mothers  the  duty  of 
themselves  attending  to  it.  Soxhlet's  bottles,  which 
prevent  any  injury  to  the  babe  from  parasites  or 
chemical  action,  are  the  best  for  the  purpose,  provided 
the  mother  herself  attends  to  the  due  cleansing  of  the 
bottle.  Considering  everything,  as  the  matter  now 
stands,  the  exact  degree  of  danger  from  food  cannot 
yet  be  determined.  Perhaps,  indeed,  the  fear  of 
bacilli  and  spores  in  the  milk  is  excessive;  but  the 
frequency  of  tuberculosis  of  the  mesenteric  glands  in 
children  compels  us  ever  to  recur  to  the  thought  of 


_  6  — 

infection  from  that  source.  Since,  therefore,  the  in- 
fectiousness of  milk  from  tuberculous  cows  has  been 
demonstrated  on  suitable  animals,  and  since  there  is 
no  evidence  against  the  application  of  that  result  to 
the  human  race,  it  is  the  duty  of  the  physician  to  in- 
struct his  patients  as  to  this  grave  danger. 

Many  other  modes  of  infection  exist  in  close 
family  life  which  may  simulate  hereditary  transmission 
and  by  which  a  tuberculous  father  or  mother  may 
exercise  an  unhealthy  influence  on  the  children.  Con- 
tamination of  the  dwelling,  furniture,  utensils  or  food 
with  sputum  is  the  more  likely  to  cause  infection  in 
susceptible  children,  the  smaller  the  dwellings,  the 
larger  the  family  and  the  less  the  well-being  and 
cleanliness  are. 

However,  plausible  as  these  modes  of  infection 
seem  from  a  theoretical  standpoint,  viewed  practically 
they  are  not  of  great  importance.  That  is  evidenced 
by  statistics  and  by  the  daily  experience  of  physicians. 
Cases  of  transmission  of  tuberculosis  from  the  sick  to 
others  who  come  into  contact  with  them,  as  husband 
and  wife,  nurses,  attendants,  etc.,  are  so  extraordin- 
arily rare,  that  its  infectiousness  cannot  be  as  serious 
as  has  been  occasionally  asserted  on  theoretical 
grounds.  In  order,  therefore,  to  explain  the  fre- 
quency of  the  disease  in  persons  descended  from 
tuberculous  parents,  we  must  still  cling  to  the  idea  of 
heredity,  and  await  a  further  development  of  knowl- 
edge to  clear  up  the  darkness  which  surrounds  it. 


—   7   — 

A  special  difficulty  connected  with  the  question 
of  heredity  lies  in  the  long  latency  of  tuberculosis  in 
childhood.  If  congenital  tuberculosis  were  like  syphilis 
or  small-pox,  where  the  babe  brings  with  it  into  the 
world  the  symptoms  of  the  disease,  the  matter  would 
be  easy  of  solution.  But  it  is  not  manifest  in  the 
newly-born.  It  is  like  those  rare  cases  of  syphilis  con- 
genita tarda,  the  symptoms  of  which  often  appear  first 
in  the  'teens  and  the  nature  of  which,  whether  con- 
genital or  post-foetal,  is  still  a  matter  of  controversy. 
That  tuberculosis  may  exist  and  perhaps  has  existed 
for  years  in  a  child  apparently  in  full  health  is  often 
learned  accidentally.  A  single  swollen  gland,  carefully 
extirpated  from  an  otherwise  blooming  and  healthy 
child,  has  been  found  to  contain  giant  cells  with 
bacilli.  How  long  were  these  in  the  body  ?  Are 
there  other  foci  of  infection  in  the  glands?  Who  can 
answer  ? 

Another  fact  deserves  to  be  mentioned  in  this 
connection.  During  the  last  great  epidemic  of  measles 
in  Munich,  Bollinger  had  repeated  opportunity,  as  he 
told  me,  to  demonstrate  on  the  bodies  of  children  who 
died  of  that  disease  the  presence  of  tubercle  bacilli  in 
the  lymphatic  glands,  especially  of  the  root  of  the  lung 
and  the  media.stinum,  although  previous  to  the  sick- 
ness the  children  had  been  apparently  healthy  and 
not  at  all  scrofulous. 

This  important  discovery  places  in  a  new  light  the 
experience  that   children   often   develop  tuberculosis 


—  8  — 

after  measles.  I'he  infection  of  measles  does  not  in- 
duce the  tuberculosis,  but  it  makes  manifest  the  latent 
disease.  Probably,  as  has  been  frequently  verified  ia 
the  scrofula  of  childhood,  most  cases  of  tuberculosis 
are  preceded  by  a  latent  glandular  tuberculosis  of 
years'  duration.  At  any  rate,  it  has  not  yet  been 
proven  that  tuberculous  infection  occurs  in  concep- 
tion or  in  foetal  life.  More  probably  it  may  occur  ia 
in  the  first  or  second  year  of  infancy  through  some 
slight  wound  (as  many  observations  would  indicate) 
or  through  milk  containing  bacilli  or  spores,  etc. 
Still,  the  difficulty  always  returns,  namely,  that  all 
these  possibilities  of  infection  are  realized  almost  ex- 
clusively in  the  children  of  parents  who  are  either 
manifestly  or  latently  tuberculous. 

Finally,  as  proof  that  tuberculosis  is  directly  con- 
tagious for  healthy  persons,  cases  of  unintentional 
"  tubercular  inoculation "  have  occurred,  where  a 
slight  injury  (such  as  drawing  a  tooth,  a  small  cut, 
etc.)  has  led  to  secondary  swelling  of  the  neighboring- 
lymphatic  glands,  and  in  these  glands,  after  extirpa^ 
tion,  giant  cells  with  tubercle  bacilli  have  been  found. 
Such  cases,  however,  are  of  doubtful  value,  for  the 
bacilli  may  have  dated  from  some  earlier  period  and 
may  have  merely  become  manifest  by  reason  of  the 
traumatic  lymphadenitis.  The  value  of  experimental 
inoculation  must  remain  doubtful  so  long  as  we  have 
no  guarantee  that  the  lymphatic  system  was  previously- 
free  from  bacilli,  and  for  such  a  guarantee  we  can 
scarcely  hope. 


CHAPTER  II. 

INHERITED  AND  ACQUIRED  PREDISPOSITION- 
SOCIAL  FOCI  OF  TUBERCULOSIS. 

Experience  compels  us  to  acknowledge  that  the 
healthy  organism  has  great  power  of  resistance  to  the 
bacillus  which  can  make  an  effective  and  permanent 
settlement  in  the  lungs,  intestines,  etc.,  onlj'-  when  cer- 
tain favorable  conditions  are  present.  These  condi- 
tions, this  as  yet  unknown  pathological  something  we 
■call  a  predisJ>ositw/i  and  mean  thereby  a  certain  con- 
stitution of  the  tissues  which  furnish  a  suitable  soil 
for  the  settlement  of  the  bacilli.  We  cannot  at  pres- 
ent get  along  without  the  supposition  of  such  a  pre- 
disposition which  may  be  either  inherited  or  acquired. 
A  disposition  exists,  in  fact,  for  other  infectious  dis- 
eases, iis  typhus,  cholera,  dysentery,  etc.,  and  why 
should  not  one  be  supposed  for  the  settlement  of  the 
tubercle  bacilli  ? 

In  what  consists  this  predisposition  which,  next  to 
heredity,  plays  the  greatest  role  in  the  etiology  of 
tuberculosis  ?  We  do  no  know.  We  know,  indeed,  in 
a  general  way,  how  a  man  looks  who  has  such  an  in- 
herited  disposition;  we  know  what  causes  may  engender 
the  disposition;  but  we  do  not  as  yet  know  its  nature 
or  the  morphological,  chemical  or  physiological 
changes  to   which  it  owes   its  origin.      Even   with    its 


external  appearance,  the  so-called  phthisical  habitus ^ 
there  is  often  but  little  to  be  made.  The  slender 
body,  the  flat  chest,  the  thin  limbs,  the  delicate  tinge, 
the  vulnerability  of  the  vessels  of  the  mucous  mem- 
brane, the  tendency  to  epistaxis  and  to  catarrhal  in- 
flammations of  the  larynx,  the  frequency  of  cardiac 
palpitation  and  of  congestions,  the  circumscribed  red- 
ness of  the  cheeks,  etc.,  all  that  is  in  many  cases 
scarcely  or  not  at  all  noticeable.  How  many  robust 
young  people  are  tuberculous  in  spite  of  their  com- 
pact bodies,  stout  muscles  and  natural  color  I  Pleie 
there  is  still  much  to  be  investigated  ! 

As  to  the  acquired  disposition,  all  those  weakening 
influences  which  so  plentifully  beset  human  life  tend 
to  its  acquisition,  such  as  insufficient  nourishment,  un- 
healthy dwellings  and  ways  of  life,  insufficient  sleep, 
lack  of  fresh  air,  worry  and  trouble,  care  of  the  sick,, 
night  vigils,  bodily  and  mental  over-exertion,  previous 
sickness,  childbed,  etc.  Of  all  these,  none  are  so 
powerful  to  weaken  the  resistance  of  tissues  and  cells, 
as  the  lack  of  fresh  air  and  the  ins2tfficiency  of  ont-door 
muscular  exercise. 

The  effect  of  these  last-named  baneful  causes  can 
be  best  studied  in  the  inmates  of  prisons,  asylums,  con- 
vents and  similar  institutions.  The  curtailment  of 
freedom  and  the  privation  of  open  air  entail  a  row  of 
factors,  the  potency  of  which  in  individuals  is  not 
easy  to  estimate.  Among  these  the  following  are 
chiefly  to  be  noted:  The  air  in  the  closed  rooms,  and 


especially  in  the  dormitories,  is  not  pure;  it  contains 
dust  and  fungi,  is  poor  in  oxygen  but  rich  in  carbon 
dioxide  and  bad  odors.  On  account  of  the  sedentary 
life,  respiration  is  not  deep  enough  and  the  lungs  are 
not  well  expanded.  The  absence  of  out-door  move- 
ment and  of  vigorous  muscular  work  diminishes  as- 
similation, and  reduces  the  need  of  nutriment;  whilst 
the  monotonous  diet  impairs  the  appetite.  Often  also 
the  quantity  and  mode  of  preparation  of  food  are  not 
what  they  should  be.  In  addition,  psychical  influences 
are  at  work,  as:  in  jails,  repentance,  longing  after 
freedom  and  family,  etc.;  in  penitentiaries,  the  enforced 
contact  with  the  dregs  of  mankind;  in  the  cellular 
prisons,  the  solitariness  of  confinement  and  the 
absence  of  all  incitement.  Here  then  we  have  a 
series  of  weakening  factors,  under  the  influence  of 
which  the  organism  sinks  into  a  depraved  condition, 
and  a  wide  door  is  opened  for  the  settlement  of  tuber- 
cle bacilli  which  certainly  are  ubiquitous  in  prisons. 

That  consumption  is  at  home  in  prisons  is  gener- 
ally recognized,  but  the  huge  proportions  in  which  the 
inmates  succumb  to  that  disease  are  not  sufficiently 
known.  Figures  furnished  by  Baer  in  the  Zeitschrift 
fur  Klinische  Medicin  show  a  mortality  from  consump- 
tion in  prisons  three  or  four  times  greater  than  out- 
side. The  mortality  from  it  in  the  race  is  generally 
reckoned  at  one-seventh,  that  is,  about  14  or  15  per 
cent.,  but  in  prisons  from  40  to  50  per  cent,  of  the 
deaths  is  due  to  consumption;  so  that  about  half  die 


from  tuberculosis.  The  ratio,  however,  varies  con- 
siderably. Thus,  the  total  mortality  from  consump- 
tion in  the  Austrian  prisons  during  four  years  amount- 
ed to  6 1  per  cent,  whilst  on  the  contrary  in  the  pris- 
ons of  Bavaria,  during  eight  years,  it  was  only  38.2 
percent.  The  death  rate  seems  to  vary  in  different 
institutions  with  the  conditions  of  the  building  and  of 
discipline;  at  any  rate  it  is  said  that  in  the  cellular  sys- 
tem tuberculosis  claims  fully  60  per  cent,  of  the  total 
mortality.* 

It  is  very  noteworthy  that  the  mortality  from  con- 
sumption reaches  its  maximum  only  in  the  later  years 
of  confinement.  This  shows  that  it  is  not  a  matter  of 
simple  infection,  but  that  in  the  majority  of  cases  a 
long-continued  deterioration  of  the  system  is  necessary 
for  the  settlement  of  the  bacilli.  Many  constitutions, 
however,  having  less  powers  of  resistance  fall  sick 
much  sooner,  especially  if  the  change  from  fresh  coun- 
try air  to  the  prison  atmosphere  has  been  very  abrupt. 
That  has  been  frequently  observed  amongst  peasants 
confined  in  prison.  This  observation  is  confirmed  by 
the  statistical  reports  of  French  and  English  military 
surgeons  who  have  found  that  the  frequency  of  tuber- 
culous disease  and  death  rapidly  diminishes  during 
war  with  its  drills  and  forced  marches,  and  again 
largely  increases  during  peace,  and  especially  during 
winter  life  in  the  barracks.     A   similar  danger  exists 


*See  appendix  for  figures  relating  to  American  prisons. — 
Tr. 


—  13  — 

for  the  crowded  population  of  great  cities,  spending, 
as  they  do,  their  days  in  dusty  and  over-crowded  work- 
shops and  their  nights  in  close  and  unclean  sleeping 
rooms. 

The  ratio  of  tubercular  disease  among  the  factory 
population  to  that  among  the  rural  classes  is  also  very 
much  in  favor  of  the  view  that  the  quantity  and 
quality  of  the  inspired  air  is  a  decisive  factor.  In 
Switzerland,  for  example,  the  mortality  from  consump- 
tion in  industrial  districts  exceeds  that  in  rural  dis- 
tricts by  more  than  double;  in  the  former  it  averages 
2.5  per  thousand,  and  in  mixed  populations  1.7,  whilst 
in  the  purely  rural  population  it  is  only  i.i  per  thou- 
sand. 

Finally,  mortality  statistics  of  elevated  localities 
show  definitely  that  the  frequency  of  consumption  is 
in  inverse  ratio  to  the  elevation,  and  that  in  very  high 
districts  (as  in  the  Mexican  cities  of  Mexico,  Puebla, 
Quito,  San  Luis  Potosi  and  Bogota,  with  an  elevation 
ranging  from  2,500  to  4,000  meters,  or  about  8,000  to 
13,000  feet)  tuberculosis  is  very  rare,  and  in  spite  of 
the  hurtfulness  of  industrial  labor  and  mining  is  not 
prevalent  among  the  laboring  classes.  The  rarity  of 
the  atmosphere  is  not  to  be  included  among  the  quali- 
ties of  an  elevated  climate  which  at  a  height  of  500 
meters  (1640  feet),  and  still  more  certainly  at 
1,000  meters,  diminish  consumption,  for  we  find 
the  same  farorable  conditions  on  the  ocean  and  the 
steppes.    Stress  is  to  be  laid  rather  on  the  rapid  move- 


—   14  — 

meiit  of  the  air  and  on  its  freedom  from  microbes 
capable  of  germmating.  The  examination  of  the 
atmosphere  for  microbes  made  by  Miquel  and  Freu- 
denreich  showed  that  they  were  entirely  absent  at  an 
elevation  of  2,000  meters,  whilst  at  560  meters,  or  1827 
feet  (namely,  at  Thun*)  scarcely  any  were  found. 
Mareau  and  Miquel  likewise  found  the  atmosphere 
on  the  high  seas  and  at  certain  places  on  the  sea  coast 
almost  free  from  them.  Thus  the  results  of  bacterio- 
logical investigation  are  in  entire  accord  with  medical 
experience.  Other  factors  may  also  contribute  to  the 
relative  immunity  of  elevated  and  ocean  atmospheres, 
as  atmospheric  pressure,  velocity  of  the  wind,  hygro- 
metric  condition,  and  to  a  certain  extent  also  the  ener- 
getic pulmonary  gymnastics  required  by  these  various 
telluric  and  atmospheric  conditions. 

I  shall  again  speak  of  this  point  when  discussing 
the  therapeutics  of  tuberculosis,  and  I  now  revert  to 
the  social  fountains  or  sources  of  the  disease. 
Amongst  these  have  already  been  mentioned  prisons 
and  badly  arranged  barracks.  Convents,  largely  at- 
tended educational  establishments,  seminaries,  orphan- 
ages, and  to  a  certain  extent  crowded  schools  also,  be- 
come influential  starting  places  of  tuberculosis  if  suit- 
able provision  is  not  made  by  sanitary  regulations 
(both  as  to  the  material  edifice  and  the  discipline)  to 
counteract  the  confinement  by  plentiful  fresh  air  and 


*A  town  of  about    5,000   inhabitants,    in   the   canton. of 
Bern,  Switzerland. — Tr. 


—  '5  — 
active  out-door  exercise.  Convents  seem  to  me  to  be 
the  most  unfavorable  in  this  regard  and  to  rank  next 
after  prisons,  because  most  of  their  inmates  fall  victims 
to  tuberculosis.  The  life  in  narrow,  ill-ventilated 
cells,  the  privation  of  fresh  air,  and  the  complete  lack 
of  bodily  exercises  and  other  movements  which  com- 
pel deep  inspiration,  are  the  chief  causes  of  the  dis- 
ease. The  same  applies  to  orphanages,  educational 
institutions  and  seminaries  where  the  pupils  are  kept 
in  conventual  seclusion  and  are  indulged  only  to  a 
very  limited  extent  in  out-door  exercise  and  play. 
The  reason  that  the  statistics  of  disease  are  not  higher 
in  such  institutions  is  because  the  confinement  is  not 
too  strict  and  especially  because  young  people  do  not 
remain  many  years  in  them. 

Most  constitutions  withstand  the  ill-effects  of  im- 
prisonment for  months  and  years,  and  not  until  a 
certain  degree  of  deterioration  has  been  reached,  do 
the  tubercle  bacilli  begin  their  destructive  activity. 
Furthermore,  statistics  of  prison  sanitation  show  that 
the  entrance  of  tuberculosis  is  frequently  facilitated 
by  inflammatory  affections  of  the  respiratory  organs, 
especially  by  pneumonias  which  have  not  undergone 
complete  resolution.  Certainly,  many  of  these  inflam- 
matory troubles  are  the  consequence  of  the  bacillary 
invasion,  rather  than  favoring  causes  of  it.  But  we 
have  frequent  opportunity  in  our  hospitals  to  see  cases 
of  pneumonia  which  in  the  beginning  resemble  in  all 
their  symptoms  genuine  croupous  pneumonia,  and  yet 


—  i6  — 

the  presence  of  bacilli  in  the  expectoration  shows- 
them  to  be  tuberculous. 

The  experiment  made  in  hospitals  of  putting 
many  consumptives  partly  among  the  other  patients- 
and  partly  in  special  wards,  is  of  special  value  for  the 
question  of  direct  contagiousness.  Tuberculous  dis- 
ease either  among  the  other  patients  or  the  attendants 
was  not  found  in  any  greater  proportion  than  outside. 
According  to  Williams'  report,  the  physicians,  nurses- 
and  employes  of  the  Brompton  Hospital  for  Consump- 
tives (the  largest  of  its  kind  in  the  world)  do  not  fait 
sick  of  tuberculosis  more  frequently  than  the  inhabi- 
tants of  populous  cities,  and  that  too  in  spite  of  poor 
ventilation,  insufficient  cleansing  of  cuspedores,  etc. 
As  a  matter  of  fact,  only  three  or  four  cases  could  be 
attributed  to  contagion  in  the  hospital.  However,  we 
must  not  attach  too  much  value  to  these  statements,, 
for  it  is  well  known  that  the  employes  of  great  hospi- 
tals are  subject  to  much  changing  about,  and  do  not 
hold  their  places  steadily  for  years. 

The  religious  orders  devoted  to  the  care  of  the 
sick  manifest  a  very  great  tendency  to  the  disease.. 
Except  those  who  nurse  patients  at  home,  the  mem- 
bers of  these  orders  are  allowed  by  their  strict  rules- 
but  little  outdoor  exercise;  and  besides  they  are  sub- 
jected to  all  the  other  injurious  influences  which  I 
have  described  as  disposing  to  tuberculosis,  such  as 
exhausting  work  from  early  morn  till  late  evening^ 
frequent  night  watches,  limited   food,  and   many  re- 


—  17  — 

ligious  exercises;  and  they  enjoy  but  rare  and  too 
brief  excursions  out  of  doors  and  into  the  country. 
It  is,  indeed,  not  to  be  wondered  that  the  organism 
should  deteriorate  under  such  a  strain  and  should 
consequently  furnish  a  suitable  soil  to  the  tubercle 
bacilli.  Right  here  among  the  Sisters  of  Charity  in 
our  large  Munich  Hospital  (whom  we  see  die  young, 
one  after  another,  of  tuberculosis,  so  that  it  may  be 
said  without  hesitation  that  this  disease  kills  50  per 
cent,  of  them),  we  observe  the  onset  of  the  infection 
without  there  being  any  hereditary  disposition  and 
simply  as  a  consequence  of  their  hospital  labors  and 
of  their  strict  observance  of  their  religious  rules.  The 
young  girls  who  enter  as  novices  are  almost  without 
exception  from  the  country,  hardy,  fresh  and  rosy 
cheeked.  After  a  few  months,  or  in  few  cases  after  a 
few  years,  that  ominous  anaemia,  which  is  the  usual 
forerunner  of  hemoptysis,  sets  in.  It  would  be  absurd 
to  imagine  that  all  these  healthy  and  fresh  country 
girls  are  hereditarily  disposed  to  tuberculosis;  yet  in 
spite  of  their  healthful  constitutions,  with  frightful 
regularity  one  after  another  falls  a  victim  to  consump- 
tion. Can  any  further  argument  be  needed  for  the 
diiect  infectiousness  of  the  disease,  for  the  dangers 
involved  in  seclusion  from  fresh  air  and  outdoor  ex- 
ercise, in  the  curtailment  of  sleep,  in  the  lack  of  rest 
and  recreation — all  of  which  are  necessitated  by  the 
straining  vocation  of  nursing  the  sick? 

3    BE 


I  will  return  to  this  subject  when  speaking  of 
prophylactic  treatment.  It  is  so  serious  that  all  who 
are  in  a  position  to  co-operate  in  improving  these  con- 
ditions should  lay  it  closely  to  heart. 

[The  author's  remarks  on  convents,  etc.,  are  of 
course  uttered  in  a  scientific,  but  friendly,  spirit. 
They  do  not,  however,  apply  so  strictly  to  similar  in- 
stitutions in  this  country,  which,  being  of  recent  origin, 
are  built  in  accordance  with  the  principles  of  modern 
scientific  construction. — Tr.] 


CHAPTER  III. 

INVASION  OF  THE  ORGANISM    BY  BACILLI— ITS 
DEFENCE-VULNERABILITY  OF  THE  APEX- 
THEORY  OF  PHAGOCYTES— THE 
LARYNX. 

I  have  now  described  all  the  conditions  which 
favor  the  settlement  of  the  tubercle  bacillus  in  the 
human  organism.  It  remains  to  briefly  state  what  is 
known  concerning  the  manner  of  its  settlement,  prop- 
agation and  diffusion,  and  concerning  the  resources 
which  the  organism  possesses  for  self-protection. 

The  usual  ways  by  which  the  bacillus  gains  ad- 
mission to  the  body  seem  to  be  through  the  digestive 
tract  in  children  and  through  the  respiratory  apparatus 
in  adults.  But  there  are  probably  exceptions.  The 
primary  cause  of  tuberculosis  of  the  intestines  and  of 
the  mesenteric  glands  in  children  would  seem  to  be 
food  containing  bacilli ;  and  of  pulmonary  and  bronchial 
tuberculosis,  the  direct  inspiration  of  bacilli.  To  ex- 
plain why  the  bacilli  fix  themselves  and  develop  in 
those  places,  we  must  necessarily  postulate  a  pathologi- 
cal condition  of  the  tissues  which  furnishes  a  suitable 
soil  for  them.  The  healthy  organism  is  probably  able 
to  free  itself  easily  from  pathogenous  micro-organisms 
by  the  action  of  its  secretory  and  excretory  appar- 
atuses, and  by  encapsulating  them  m  cells,  which  very 


20    

likely  destroys  or,  at  least,  curtails  their  activity.  If 
the  body  did  not  possess  such  means  of  protection^ 
the  maintenance  of  its  integrity  in  the  presence  of 
ubiquitous  pathogenic  micro-organisms  would  be  im- 
possible. The  microbes  of  tuberculosis  especially 
would  be  noxious  to  all  men  on  account  of  their  per- 
sistence for  longer  or  shorter  periods  in  their  habitats, 
for  example,  in  the  consumptive  wards  of  hospitals. 
Yet,  as  I  have  already  mentioned,  Dr.  Williams  has 
shown  that  tuberculosis  among  the  physicians,  nurses 
and  employes  of  Brompton  Hospital  is  not  more  fre- 
quent than  among  city  people  generally.  But  where 
the  exposure  to  infection  is  attended  by  a  fatal  dis- 
position to  consumption  and  there  is,  as  we  must  sup- 
pose, less  resistance  of  the  cells  to  the  invasion,  there 
the  seeds  will  be  planted  and  will  find  the  requisite 
conditions  for  increase  and  propagation. 

I  have  said  that,  as  far  as  is  yet  known,  the  pro- 
tective power  of  the  body  lies  in  the  normal  function 
of  digestion,  in  the  secretion  of  the  bronchial  mucous 
membrane,  and  in  the  energetic  activity  of  its  amoeboid 
cells.  We  may  consider  it  established  that  normal 
gastric  juice  digests  or" at  least  sterilizes  bacilli  intro- 
duced with  food.  On  the  other  hand,  disturbances  of 
digestion,  neutral  or  alkaline  reaction  of  the  gastric 
juice,  and  fermentative  or  putrefactive  changes  in  the 
contents  of  the  stomach  must  open  a  wide  door  to 
their  progress. 

The  invasion  of  bacteria  through  the  respiratory 


—    21    

tract  presents  the  greatest  danger  on  account  of  their 
ubiquity.  That  the  organism  does  resist  the  admis- 
sion of  foreign  bodies  with  the  inspired  air  is  known 
from  the  study  of  sputum  during  life  and  of  the  lungs 
post  mortem.  We  find  particles  of  dust  and  other 
minute  foreign  bodies  taken  up  by  large  cells,  whose 
source  is  not  yet  ascertained.  In  my  opinion,  these 
cells  do  not  originate  in  the  alveolar  epithelium,  but 
they  are  furnished,  as  I  shall  hereafter  show,  by  the 
bronchial  mucous  membrane  (by  its  beaker-cells)  and 
perhaps  also  by  the  sub-epithelial  layer.  Where  dust 
is  only  moderately  inspired,  as  among  bakers  and 
smiths,  or  by  staying  in  rooms  filled  with  tobacco, 
wood  or  coal  smoke,  the  expectoration  will  show  an 
abundance  of  large  round  cells  containing  particles  of 
coal.  But  where  the  inhalation  of  dust  is  continuous 
as  among  miners,  mirror-polishers,  etc.,  this  cell 
activity  is  not  adequate  to  the  task  of  its  removal,  and 
the  dust  is  rather  taken  into  the  alveolar  epithelium 
and  lymph  stomata  and  partly  stored  up  in  the  inter- 
stitial tissues  and  partly  carried  through  the  lymphatics 
to  the  bronchial  glands.  The  fine  observations  of 
Zenker  and  Merkel  on  the  pulmonary  tissue  of  mirror- 
polishers  impregnated  with  the  dust  of  "  English- 
red  "  *  furnish  the  most  convincing  illustrations  of  this 


*"  English-red  "  is  a  powdery  deposit  in  the  distillatioa 
of  sulphuric  acid  from  sub-sulphate  of  iron  (green  vitriol).  It 
consists  of  iron  oxide  and  a  little  sub-sulphate  of  iron.  It  is 
much  used  in  polishing. — Tr. 


condition.  The  power  of  resistance  of  the  lungs,  the 
ability  to  eliminate  foreign  bodies,  is  therefore  limited, 
but  still  very  considerable.  It  is  very  probable  that 
the  number  of  dust-eating  cells  and  their  energy  in 
swallowing  foreign  particles  depend  on  a  certain  de- 
gree of  reactive  power  in  the  bronchial  mucous  mem- 
brane and  the  walls  of  the  alveoli,  and  that  the  extru- 
sion of  the  cells  depends  on  the  energy  of  the  move- 
ment of  the  cilia  and  on  the  efforts  at  expectoration. 
Any  diminution  in  the  energy  and  reaction  of  the 
epithelial  cells  of  the  respiratory  tract  is  an  important 
factor  for  the  domiciliation  of  the  bacilli.  This  is 
shown  by,  among  other  things,  the  lack  of  reaction 
observable  in  the  beginning  of  tuberculous  infection, 
as  Baer  noticed  in  prisoners  and  as  we  ourselves  see 
in  our  Sisters  of  Charity.  The  patients  become  thin, 
anaemic,  without  appetite  or  strength.  Neither  cough, 
dyspnoea,  nor  other  respiratory  trouble  is  present,  yet 
the  physical  examination  will  disclose  an  infiltration 
in  one  or  both  apices  of  the  lungs.  Only  the  higher 
grades  of  cell  debilitation  (as  found  in  prisons  and 
convents)  are  characterized  by  such  a  deficiency  of 
reactive  power,  but  they  entitle  us  to  draw  inferences 
as  to  the  lesser  grades. 

I  will  here  consider  a  question  which  is  very  im- 
portant from  a  practical  point  of  view,  namely  why 
the  apices  of  the  lungs  arc  the  favorite  site  of  tuberculosis. 
That  they  are  is  a  matter  of  daily  observation  among- 
medical  men.     Hitherto   it   was   generally   supposed 


—  23  —       . 

that  the  settlement  of  the  tubercle  bacilli  by  prefer- 
ence there  was  due  to  a  deficient  inspiratory  expansion 
of  the  parts,  producing  an  insufficient  ventilation  of 
the  local  bronchioles  and  alveoli  and  this  in  turn  lead- 
ing to  stagnation  of  the  secretions  and  inflammatory 
products.  Thus  the  frequency  of  apical  tuberculosis 
in  persons  addicted  to  a  sedentary  mode  of  life,  and 
especially  to  a  stooping  posture  (as  tailors  and  others) 
was  accounted  for. 

Hanau  has  lately  promulgated  the  view,  and  I 
think  on  good  grounds,  that  this  local  disposition  of 
the  apices  is  due  not  to  deficient  inspiration  but  to 
more  difficult  expiration.  That  the  apices  possess  a 
good  power  of  inspiration  is  well  shown  by  their  con- 
dition in  cases  of  anthracosis  (miner's  lung,  grinders' 
phthisis),  occurring  in  industrial  work  and  produced 
in  Arnold's  experiments  on  animals.  In  such  cases, 
the  apices  are  the  parts  soonest  and  most  affected. 
And  as  to  the  effects  of  a  stooping  posture,  it  changes, 
in  men,  the  physiological  costo-abdominal  inspiration 
almost  to  the  costal  form,  because  the  downward 
movement  of  the  diaphragm  is  impeded  by  the  narrow- 
ing of  the  abdominal  cavity;  but  in  women,  costal 
respiration  is  physiological,  so  that  in  their  case  it  is  of 
no  avail  to  suppose  an  insufficient  expansion  of  the 
lungs.  The  weakness  of  the  theory  of  inspiration 
lends  more  probability  to  the  expiratory  theory. 
Mendelssohn  first  deduced  theoretically,  and  I  have 
shown  by  observations  made  on  individuals  with  weak 


—    24    — 

thoracic  muscles,  that  a  backward  rush  of  air  occurs 
in  the  upper  lobes  during  forced  expiration,  because 
the  superior  part  of  the  thorax  is  deficient  in  contrac- 
tile muscles.  Consequently,  in  coughing,  the  air  not 
only  stagnates  and  momentarily  stands  still  under 
the  strong  pressure,  but  (what  is  very  important  for 
the  subject  under  consideration)  the  expectoration  of 
foreign  particles  and  bacteria  out  of  the  apices  is 
hindered  and  the  contents  of  the  bronchi  are  even 
carried  inwards  to  the  alveoli  by  the  reverse  current 
of  air.  The  spiral  course  of  the  smallest  bronchioles 
may  be  in  the  apices  an  impediment  as  much  to  the 
aspiration  of  dust  and  bacilli  as  to  their  expiratory- 
expulsion.  At  all  events,  this  anatomical  condition  is 
not  at  all  favorable  but  rather  is  very  unfavorable  to 
the  movement  of  inspired  particles.  I  can  con- 
sequently agree  with  Hanau  that  the  apices  which 
are  relatively  most  favorable  for  the  inspiration  of 
dust  and  micro-organisms  are  also  most  unfavorable 
for  their  expulsion.  If  once  the  tubercle  bacilli  reach 
them,  they  find  a  sort  of  resting  place  whence  they 
can  press  into  the  lymphatics  between  the  epithelial 
cells  and  establish  themselves  in  the  sub-epithelial 
layer. 

That  bacilli  may  enter  through  the  lymph  and 
blood  routes  as  well  as  with  the  inspired  air  is  beyond 
question.  But  in  the  lungs,  such  a  manner  of  en- 
trance  could  be  inferred  only  from  a  primary  in- 
fection of  the  walls^of  the  lymphatics  and  vessels. 


—  25  — 

When  the  bacillus  has  crowded  into  the  tissues  it 
starts  up  by  virtue  of  its  biological  qualities  (which  we 
do  not  yet  intimately  know)  an  irritation,  and  following 
that  an  inflammatory  reaction.  Here,  then,  begins  that 
struggle  between  the  living  cells  and  the  parasites,  which 
has  been  so  much  spoken  about  of  late.  Naegeli  has  al- 
ready characterized  the  struggle  between  the  bacillus 
and  the  organic  cells  as  the  process  in  the  infectious 
diseases,  on  the  issue  of  which  the  life,  disease  or 
death  of  the  individual  depends.  The  result  is  de- 
termined on  one  side  by  the  vital  energy  of  the  cells 
and  on  the  other  by  the  infectiousness  of  the  bacillus. 
If  the  cells  conquer,  the  bacillus  is  destroyed  before  it 
has  time  to  injure  the  organism;  if,  on  the  contrary, 
they  should  be  conquered,  there  is  no  hinderance  to 
the  settlement,  growth  and  diffusion  of  the  bacilli. 

Thfs  generally  accepted  view  of  the  nature  of  in- 
fection and  the  part  taken  by  the  living  cells  in  ward- 
ing it  off  has  undergone  a  still  further  development  in 
Metschnikoff's  doctrine  of  phagocytes,*  which  has 
much  of  interest  in  spite  of  the  ambiguity  of  the  pheno- 
mena observed  by  him. 

According  to  Metschnikoff,  the  oflSce  of  defence 
belongs  to  the  so-called  phagocytes  which  are  recruited 
from  the  leucocytes  and  fixed  connective  tissue  cells. 
The  irritation  set  up  by  the  invasion  of  the  bacilli  calls 
them  forth  to  the  battle   field  and  they  at  once  set 


*  Glutton-cells,  from  cpdyo^,  glutton,  and  kvroi,  cell.     The 
German  is  Fresszellen, — Tr. 


—    26    — 

about  devouring  the  intruder^,  that  is,  they  take  them 
into  their  bodies  and  digest  them,  thereby  rendering 
them  sterile.  There  are  two  classes  of  phagocytes, 
the  large  and  the  small  ones  [makrophage?i,  mikrophagen). 
Among  the  former,  Metschnikoff  places  the  epitheloid 
cells  of  the  connective  tissue,  and  among  the  latter 
the  leucocytes  with  lobed  nuclei  {gelappt  kernigen). 
In  his  latest  publication  (Virchow's  Archiv.,  vol.  107, 
No.  2)  he  states  that  the  streptococcus  of  erysipelas  is 
taken  up  only  by  the  small  phagocytes,  and  that  these 
latter  are  then  taken  into  the  cell-bodies  of  the  larger 
ones  and  there  digested.  Likewise  the  gonococcus  is 
devoured  only  by  the  small  phagocytes,  whilst  in 
anthrax  in  rabbits  and  Guinea-pigs  the  bacilli  are 
taken  up  Only  by  the  larger  ones.  In  tuberculosis, 
both  kinds  of  phagocytes  are  active  in  resisting  the  in- 
vasion. The  larger  ones  take  as  epitheloid  and  giant 
cells  a  prominent  part  in  the  contest,  but  the  smaller 
ones  first  begin  it  and  also  overpower  a  larger  number 
of  invaders.  Even  in  twenty  hours  after  inoculating 
the  subcutaneous  tissues  of  a  rabbit  or  the  anterior 
chamber  of  its  eye  with  a  pure  culture  of  tubercle 
bacilli,  Metschnikoff  found  many  of  the  small  phago- 
cytes entirely  gorged  with  bacilli,  that  is,  at  a  time 
when  there  could  not  be  any  reaction  on  the  part  of 
the  fixed  cells.  The  larger  phagocytes  do  not  take 
part  in  the  contest  until  later,  inasmuch  as  they  swallow 
up  both  single  bacilli  and  dead  small  phagocytes.  In 
this  way  characteristic  conglomerates  are  formed,   in 


—    27    — 

which  masses  of  devoured  substances  are  found,  so 
that  the  nuclei  of  the  large  phagocytes  are  covered  up, 
but  still  demonstrable. 

The  theory  of  phagocytes  has,  however,  met  with 
vigorous  opposition  in  various  quarters.  Its  opponents 
admit  that  bacilli  are  taken  up  into  the  bodies  of  large 
and  small  cells;  but  they  see  in  that  no  tendency  to  a 
cure  but  only  a  mechanical  intussusception  of  the 
bacilli  by  which  these  gradually  undergo  certain 
changes  of  form.  Metschnikoff  holds  that  the  pro- 
toplasm of  the  cells  kills  the  bacilli,  which  gradually 
break  up,  or  at  least  lose  their  virulence  and  become 
incapable  of  infection. 

These  observations  on  the  relations  of  the  phago- 
cytes to  the  invading  tubercle  bacilli  are  of  special 
interest  for  our  subject,  and  we  await  with  great  ex- 
pectation the  further  contributions  which  Metschnikoff 
promises  on  the  subject  of  tuberculosis,  and  the  dis- 
cussion which  will  spring  from  them. 

From  a  clinical  standpoint,  it  would  aid  the  com- 
prehension of  the  stages  of  tubercular  infection  to 
suppose  that  in  a  healthy  organism  an  invasion  of 
bacilli  should  be  at  once  overcome  and  made  power- 
less; that  in  a  predisposed,  organism  with  weakened 
vital  energy  of  the  cells,  the  virulence  of  the  invasion 
should  not  be  wholly  destroyed,  but  should  be  tem- 
porarily made  ineffective  by  encapsulation  in  the  fixed 
connective  tissue  cells;  and  that  in  weak  organs,  their 
storming  in  should  bear  down  all  opposition  and  rap- 
idly destroy  the  individual. 


—    28    — 

I  should  call  attention  also  to  the  possibility  of 
the  respiratory  tract  being  flooded  by  putrefactive 
products  containing  bacilli,  which  being  inspired  lead 
to  rapid  softening  of  the  lungs  and  sweep  the  patient 
away.  Such  an  auto-infection  of  the  previously 
healthy  parts  of  the  lungs  furnishes  a  satisfactory  ex- 
planation of  the  widespread  tuberculous  pneumonias 
which  so  frequently  develop  in  the  later  stages  of 
chronic  tuberculosis. 

Finally,  a  word  about  laryngeal  tuberculosis.  It 
is  almost  without  exception  a  secondary  affection,  that 
is,  an  accompaniment  of  a  primary  pulmonary  tuber- 
culosis. Considering  that  tuberculosis  may  be  ac- 
quired by  inhalation,  primary  laryngeal  tuberculosis 
cannot  be  set  down  as  impossible.  The  epithelium, 
however,  seems  to  furnish  a  very  strong  protection 
against  enemies  from  without.  Dr.  Kukoff  made  an 
anatomical  investigation  of  this  point  in  our  patholog- 
ical institute.  He  used  a  freezing- microtome  and 
examined  fresh  larynxes  from  consumptives.  In  no 
case  was  he  able  to  detect  a  crowding  in  of  the  bacilli 
from  without,  as,  for  example,  from  sputum  hanging 
in  the  larynx;  but,  on  the  contrary,  he  found  the  epi- 
thelium well  preserved,  and  saw  the  bacilli  pushing 
from  the  sub-epithelial  cellular  layer  out  in  the  inter- 
cellular lymph  passages  of  the  epithelium  towards  the 
periphery.  Nevertheless,  there  is  no  doubt  that  local 
infection  may  come  from  bacilli  in  the  sputum  if  there 
is  the  slightest  erosion.     That,  however,   would  not 


bear  upon  the  origin  of  laryngeal  tuberculosis,  for 
which  we  must  have  recourse  exclusively  to  the  blood 
and  lymph  streams  in  the  laryngeal  mucous  mem- 
brane. 

The  question  of  the  curability  of  laryngeal  tuber- 
culosis is  now  generally  decided  in  the  affirmative,  that 
is,  in  the»sense  of  the  foregoing  view  of  the  curability 
of  pulmonary  tuberculosis.  It  certainly  is  not  often 
the  case  that  tuberculous  ulcers  of  the  larynx  heal, 
but  I  am  very  certain  that  it  is  possible,  for  I  have 
seen  several  cases  quickly  heal  up  under  the  influence 
of  a  general  quiescence  of  the  tuberculous  process, 
and  when  the  patients  died  (after  some  years  from  re- 
newed outbreak  of  the  tuberculosis)  I  was  able  to  note 
the  firm  scars  of  the  ulcers.  All  experienced  laryn- 
gologists  must  have  observed  similar  cases. 

From  all  that  has  been  said,  it  is  evident  that 
aaany  questions  remain  to  be  answered,  before  all  the 
conditions  of  the  life,  work,  and  death  of  the  tubercle 
bacillus  become  so  well  known  that  we  shall  be  able 
to  extirpate  this  hereditary  enemy  of  the  human  race. 
But,  thanks  to  the  discovery  of  Koch,  enormous  pro- 
gress has  been  made  during  the  past  six  years  in  the 
study  of  the  etiology  and  pathology  of  tuberculosis. 
The  zeal  with  which  the  study  is  pursued  and  the 
strict  methods  used  guarantee  further  and  steady  ad- 
vancement, and  in  it  clinical  medicine  will  as  far  as 
possible  take  an  active  share. 


PART  SECOND. 


The  Diagnosis  of  Pulmonary  Tuberculosis. 


CHAPTER  I. 

THE   PARALYTIC  THORAX-THE  APICES 

It  is  not  my  intention  to  recapitulate  the  entire 
symptomatology  of  pulmonary  tuberculosis.  I  shall 
limit  myself  to  some  matters  which  are  of  practical  im- 
portance, especially  for  diagnosis.  The  reader  will 
perhaps  find  some  new  points  of  view  valuable  for 
judging  individual  cases  and  for  ascertaining  thera- 
peutic indications.  I  first  select  some  of  the  symp- 
toms made  known  by  physical  examination. 

Let  us  consider  the  form  of  the  thorax  in  pul- 
monary tuberculosis.  Long  and  flat  and  with  scant 
antero-posterior  diameter,  it  produces  the  impression 
that  the  arched  walls  have  sunk  in;  that  is,  the  vertical 
diameter  has  been  lengthened  at  the  expense  of  the 
sterno-vertebral  diameter.  This  impression  is  intensi- 
fied by  the  thin  adipose  and  muscles  and  by  the  slight 
elevation  of  the  wall  in  inspiration.  The  phrase 
"paralytic   thorax"    aptly   expresses    the    condition. 


-  3'  — 
The  prominence  of  the  clavicles  is  partly  due  to  the 
meagerness  of  the  soft  tissues  and  becomes  very 
marked  by  the  sinking  in  of  the  chest  wall  orer  the 
shrunken  apices.  The  prominence  of  the  shoulder- 
blades  is  likewise  caused  by  the  scantiness  of  the  fat  and 
the  thinness  and  atony  of  the  trapezeus,  rhomboideus, 
latissimus  dorsi,  and  serratus  muscles;  but  it  becomes 
very  pronounced  when  there  is  simultaneous  kyphosis,* 
that  is,  excessive  curvature  of  the  upper  thoracic  ver- 
tebrae with  compensatory  lordosis*  of  the  lower  thor- 
acic and  lumbar  vertebrae — a  condition  found  very 
frequently  in  long  chests. 

The  flatness  of  the  thorax  and  the  smallness  of 
its  antero-posterior  diameter  can  be  clearly  seen  on 
lateral  inspection  when  the  patient's  arms  are  elevated. 
Diagrams  drawn  by  means  of  Woillez's  cyrtometer 
make  it  still  more  evident.  This  instrument  is  first 
accurately  adjusted  to  the  thorax  and  then,  after  its 
removal  and  fixation,  the  circumference  of  the  chest 
is,  by  its  means,  marked  out  on  a  large  sheet  of  paper, 
on  which  the  diameters  have  been  drawn.  The  result 
is  an  imaginary  cross-section  of  the  thorax  which  very 
clearly  shows  the  difference  between  the  normal  and 
the  paralytic  forms.  Several  such  sections  are  here- 
with presented,  but  necessarily  on  a  reduced  scale — a 
fact  that  is  to  be  regretted,  because  the  actual  propor- 


*  Kyphosis  is  an  exaggerated  condition  of  the  nornaal 
dorsal  curve;  lordosis  is  an  excessive  lumbar  curve;  and  a 
lateral  curvature  of  the  spine  is  called  scoliosis. — Tr. 


—  32  — 

tions  would  be  very  instructive.  They  are  made  on  a 
plane  through  the  spinous  process  of  the  ninth  thor- 
acic vertebra  and  the  base  of  the  processus  xiphoi- 
deus,  and  all  are  from  patients  between  twenty-five 
and  forty  years  of  age.  The  woman  (Fig.  i)  and  the 
man  (Fig.  2)  were  cases  of  advanced  phthisis.  The 
normal  thorax  (Fig.  3)  was  that  of  a  healthy,  low- 
sized,  stoutly-built  butcher.  For  purposes  of  compari- 
son, an  emphysematous  thorax  is  presented  in  Fig.  4, 
in  which  the  length  of  the  sterno-vertebral  diameter  i& 
to  be  noted.  Allowance  must  be  made  for  the  thin- 
ness of  the  chest  walls,  which,  of  course,  makes  the 
paralytic  thorax  more  pronounced;  but,  as  the  cyrtom- 
eter  is  always  tightly  applied,  the  discrepancy  from 
this  cause  cannot  be  reckoned  as  more  than  1.5  cm. 
(.6  inch).  The  principal  difference  between  the  nor- 
mal and  the  paralytic  thorax  consists  in  the  diminu- 
tion of  the  sterno-vertebral  diameter  and  its  propor- 
tion to  the  transverse  diameter. 

It  is  of  little  use  to  give  absolute  measurements 
of  the  sterno-vertebral  diameter  in  the  normal  thorax 
because  the  size  of  the  thorax  varies  considerably 
within  the  limits  of  health.  One  may,  however,  say 
that  in  men  of  medium  size  (170  to  175  cm.  i.  e.  66  to 
68  inches)  the  antero-posterior  diameter  should  not 
be  less  than  twenty  centimeters  (7.8  inches);  in 
phthisical  men,  it  may  be  as  small  as  eighteen  centi- 
meters (7  inches);  and  in  phthisical  women,  it  may  be 
be  reduced  even   to  fifteen  centimeters   (5.9   inches). 


—  33  — 

Riihle  very  properly  points  out  that  the  paralytic 
thorax  in  fat  persons  who  become  tuberculous  may  be 
concealed  at  first  glance  by  the   amount  of   adipose 


FIG.  I. 

Consumptive  woman,  28  years  old. 

Narrowing  of  left  side. 


FIG.   2. 

Consumptive  man,  2!;  vears  old.    The 

soft  tissues  very  much  emaciated. 


FIG.  3. 

Monn&l  thorax,  thick  mu«cles 

a  man  32  years  old. 


From  FIG.   4. 

Expanded  thorax  of  an  emphysematous 
patient,  40  years  old. 


—  34  — 
tissue.     But  even  in  such  cases,  and  especially  if  there 
is  progressive  emaciation,  one  may  by  close  observa- 
tion ascertain  its  presence. 

That  the  paralytic  thorax  may  be  found  in  tall, 
rapidly  grown  individuals  who  are  entirely  healthy 
and  not  tuberculous,  is  certain.  Doctors  who  examine 
recruits  for  military  service  have  opportunity  often 
enough  to  see  such  cases.  Still  its  occurrence  in 
health  is  a  rarity  and  ought  always  excite  suspicion  of 
a  tuberculous  disposition. 

In  the  physical  examination,  the  closest  attention 
should  be  paid  to  the  apices  of  the  lungs.  Since  they 
are,  in  far  the  greatest  number  of  cases,  the  locality 
where  the  bacilli  first  lodge,  it  is  to  be  expected  (and 
experience  justifies  the  expectation)  that  they  should 
manifest  the  earliest  physical  signs  of  the  disease. 
The  anatomical  conditions  are  most  favorable  for  their 
examination  inasmuch  as  the  apex  proper  lies  above 
the  first  rib,  the  clavicle  and  the  upper  edge  of  the 
scapula,  that  is,  to  a  certain  extent  outside  the  thor- 
acic skeleton  and  projecting  above  it.  Hence  it  is 
possible  to  accurately  mark  out  the  borders  and  to 
ascertain  to  what  extent  the  apices  contain  air.  A 
sharp  outlining  of  the  inflated  apices  towards  the 
larynx,  cervical  muscles  and  vertebral  column  presents 
no  difficulty  to  anyone  moderately  skilled  in  topo- 
graphical percussion.  Approximately  correct  results 
can  be  had  by  using  the  finger  to  percuss,  but  the 


—  35  — 
limits  can  be  accurately  defined  by  the  use  of  my 
ivory  wedge-shaped  plessimeter.  It  is 
intended  for  outlining  organs  and  es- 
pecially for  determining  the  borders 
of  the  apices.  The  instrument  (of 
which  a  side  view,  actual  size,  is  given 
in  Fig.  5)  is  to  be  applied  with  its  nar- 
row end  (2  mm.  or  .08  inch,  wide) 
to  the  skin  whilst  the  percussion  is 
made    on    its    broad  end  (17  mm.   or 

.6  inch). 
FIG.   5.  ' 

On  physical  grounds  which  it  would  take  too  long 
to  detail,  I  recomend  that  percussion  be  always  made 
from  above  downwards.  Starting  from  the  neck,  the 
edges  of  the  expanded  apices  should  be  located,  and 
the  boundaries  between  the  dull  note  of  the  muscles 
and  bones,  the  tympanitic  note  of  the  larynx  and  the 
note  of  the  apices  should  be  marked  with  pencil  or 
ink.  In  this  way  one  moves  gradually  from  the 
larynx  to  the  vertebral  column.  The  boundaries  on 
both  sides  being  thus  determined,  both  apices  should 
be  compared  with  regard  to  their  capacity.  Percus- 
sion of  the  supra-clavicular  depression  should  be  made 
from  behind  towards  the  front,  otherwise  the  clavicle 
will  be  in  the  way,  and  the  finger  cannot  be  firmly  ap- 
plied m  the  depression.  Corresponding  parts  of  the 
supra-clavicular  grooves  should  be  compared  in  this 
manner.  In  health,  the  external,  middle  and  innermost 
parts  of  these  grooves  return  different  notes,  the  in- 


-  36  - 

nermost  being  most  intense  and  the  outermost  least 
so.  Consequently  great  care  must  be  taken  to  com- 
pare, in  patients,  only  like  parts  with  each  other. 
Similar  precautions  must  be  used  in  percussing  and 
comparing  the  supra-spinous  regions  and  the  spaces 
between  them  and  the  vertebral  column.  Results  will 
be  more  reliable,  the  more  firmly  the  finger  is  applied 
and  the  more  equally  percussion  is  made  on  it  with 
the  middle  finger  of  the  right  hand.  The  plessimeter 
does  not  fit  well  into  the  supra-clavicular  grooves  and 
the  hammer  does  not  give  nearly  as  fine  results  as  the 
simple  finger;  hence  their  use  for  those  parts  is  not 
recommended. 

The  height  of  the  two  apices  is  surprisingly 
similar,  as  is  evident  from  simple  inspection.  But  if 
one  desires  to  express  the  height  in  figures,  it  is  best 
(in  view  of  the  peculiar  configuration  of  the  parts)  to 
measure  along  the  edge  of  the  trapezius  from  the  top 
of  the  apex  to  the  outer  border  of  the  acromion,  the 
arms  of  the  patient  being  allowed  to  hang  down.  The 
uniformity  is  all  the  more  wonderful,  as  it  depends  on 
the  configuration  not  only  of  the  neck  and  upper 
chest,  but  also  of  the  scapulae.  Measurements  from 
the  tip  of  the  lungs  straight  down  to  the  clavicles  are 
not  reliable.  The  complete  equality  of  the  height  of 
two  apices  in  health  naturally  causes  any  departure 
from  the  normal  proportion  in  one  of  them  to  be  very 
suspicious.  Hence  the  great  value  of  a  comparative 
determination  of  the  height  of  the  apices  in  the  begin- 


—  37  — 
ning  of  tuberculosis  as  well  as  in  its  later  stages.  In 
the  Natural  Science  Association  meeting  at  Frankfurt, 
in  1867,  I  showed  to  the  Section  of  Medicine,  both  by 
photographs  and  by  demonstration  on  the  living  sub- 
ject, the  great  diagnostic  value  of  these  things.  I 
fear,  however,  that  the  medical  fraternity  was  not 
sufficiently  impressed  with  the  importance  of  ascer- 
taining the  height  of  the  apices.  I  should  not  omit 
to  mention  that  Prof.  Seitz  (then  at  Giessen)  had 
already  in  1862  called  attention  through  one  of  his 
pupils  to  the  importance  of  determining  this  height  by 
percussion. 

As  to  the  clinical  value  of  a  considerable  varia- 
tion in  the  height  of  the  apices,  I  will  say  that  flatness 
of  one  or  both  is  usually  found  with  large  or  small  . 
infiltrations  at  the  apex.  The  shrinkage  which  causes 
the  flatness  occurs  in  the  new  connective  tissue,  which 
is  a  product  of  reactive  interstitial  pneumonia.  As 
the  infiltrate  softens  and  degenerates,  together  with 
the  alveolar  tissue  of  the  infiltrated  lobules,  the  young 
cicatricial  tissue  replaces  it  step  by  step.  In  the  be- 
ginning the  defect  of  tissue  is  pretty  considerable,  but 
it  is  compensated  for  by  thickening  of  the  pleura  and 
by  vicarious  distension  of  the  neighboring  air-contain- 
ing pulmonary  tissue.  The  apex  suffers  most  diminu- 
tion of  height  when  the  cicatrix  is  widespread  and 
ramifying  and  contains  no  considerable  cavities.  In- 
deed, a  considerable  flattening  of  the  apices  may 
result  favorably  in  this  manner,  namely,  in   cicatriza- 


-  38- 

tion  and  healing,  and  that  all  the  sooner,  if  there  are 
no  physical  signs  of  cavities.  A  few  schematic  figures 
will  illustrate  the  usual  course  of  nature's  curative 
process  in  apical  tuberculosis.  Fig.  6  represents  the 
condition  of  infiltration;  Fig.  7,  the  advanced  soften- 
ing and  cicatrization,  with  vicarious  distension  of  the 
adjoining  air-holding  tissues;  and,  finally.  Fig.  8  shows 
the  arching  over  of  the  contracted  cicatrix  by  the 
compensatory  emphysema  of  the  neighboring  parts. 


FIG.  6. 


FIG.   7. 


FIG.  8. 


In  this  last  stage  of  simple  cicatrization  and 
diminution  of  the  apex,  there  are  usually  as  yet  only 
very  slight  dullness  to  be  noticed  on  percussing,  and 
a  heightened  or  weakened  vesicular  murmur  with 
prolonged  increased  or  diminished  bronchial  expira- 
tion, but  no  rales — a  sign  that  there  are  probably  no 
progressive  process  and  no  open  cavities  to  keep  up 
softening  and  secretion. 

To  a  certain  extent,  the  flatness  of  the  apex  may- 
be finally  compensated  for  by  an  increased  emphysema 
of  the  upper  lobes,  which  are  more  and  more  raised 
up  over  the  cicatrix.  This  compensation  occurs 
especially  when  the  sunken  upper  part  of  the  thorax 
is   gradually   enlarged   by   strong   inspiration,  as  has 


—  39  — 
been  observed  in  pulmonary  gymnastics  after  cicatriza- 
tion following  apical  tuberculosis.  Here  the  scaleni 
muscles  count  as  special  factors.  The  enlargement 
of  the  upper  part  of  the  thorax  must  be  accompanied 
by  compensatory  emphysema  of  the  parts  surrounding 
the  cicatrix  and  by  a  corresponding  elevation  of  the 
apices.  Such  elevations  of  earlier  depressions  can  be 
followed  clinically  with  sufficient  exactitude.  The 
emphysema  around  the  cicatrix  might  be  characterized 
as  a  sort  of  protective  measure  against  new  settle- 
ments of  bacilli,  for  experience  teaches  that  emphy- 
sematous pulmonary  tissue  is  not  a  favorable  soil  for 
bacilli  cultures. 

We  thus  see  in  what  manner  the  process  of  spon- 
taneous cure  occurs.  Frequent  exceptions  to  this 
course  are  found.  Frequently  one  or  more  cavities 
are  met  with  in  the  cicatrix.  These  are  filled  with 
firm,  inspissated,  cheesy  secretion,  or,  communicating 
with  the  bronchi  and  secreting  for  a  long  time,  they 
may  finally,  through  progressive  cicatrical  contraction, 
end  in  solidification.  Such  cavities  in  the  cicatricial 
tissue,  either  enclosed  or  still  secreting,  are  less  favor- 
able, inasmuch  as  they  furnish  a  suitable  soil  for  the 
development  of  the  bacilli,  whilst  bacilli  in  the  firm 
cicatricial  tissue  have  only  a  counterfeit  existence. 
The  cheesy  deposits  in  the  cicatrix  are  usually  rich  in 
bacilli  and  often  may  undergo  softening  even  at  a  late 
period  and  lead  to  a  local  renewal  of  the  trouble  or  to 
a  general  infection  of  the  system.     Such  caseous  foci 


—  4°  — 
and  small  caverns  are  volcanoes  which  may  remain 
quiescent  during  long  years  or  even  during  the  entire 
life.  Often  enough,  however,  an  eruption  takes  place 
unexpectedly  and  to  the  great  surprise  of  the  physi- 
cian, especially  if  he  have  known  nothing  of  the 
earlier  changes  and  if  the  patient  have  reached  an  ad- 
vanced age.  Acute  tuberculosis  of  old  people  is  com- 
moner than  is  usually  supposed,  and  the  post  ?nortem 
almost  always  shows  remains  of  the  old  tuberculous 
process  along  side  of  the  new  eruption.  The  exist- 
ence of  such  a  volcano  may  be  clinically  inferred,  if 
the  sputum  continues  to  show  bacilli,  although  the  in- 
dividual may  otherwise  seem  entirely  restored,  and  if 
the  dulness  of  the  percussion  note  over  the  apex  does 
not  fully  clear  up,  as  is  wont  to  be  the  case  in  simple 
cicatricial  contraction  with  arching  over  of  the  emphy- 
sematous neighboring  tissue. 

There  are  families  in  which  this  benevolent  form 
of  tuberculosis  (if  I  may  so  term  it)  is  hereditary,  and 
in  which,  consequently,  healing  of  the  tubercle  focus 
in  the  apices  and  roots  of  the  lungs  forms  the  rule.  In 
the  members  of  such  families  we  may  observe  the  de- 
velopment of  the  apex  trouble  at  first  unilaterally  and 
usually  with  repeated  hemoptyses,  and  we  may  after- 
wards trace  the  clearing  up  of  the  dulness  and  the 
contraction  of  the  apex.  Then  after  a  long  time  the 
other  apex  takes  its  turn  and  we  find  the  same  retro- 
grade processes  in  the  same  sequence. 

If  the   original    tuberculosis   which     caused    the 


—  41  — 
shrinkage  of  the  apices  was  not  recognized  at  the 
proper  time,  it  may  be  worth  while,  in  order  to  judge 
later  events  (such  as  the  occurrence  of  a  relapse)  or 
to  explain  special  tuberculous  affections  (as  of  the 
vertebrae  or  genito-urinary  tract,  or  tuberculous  dis- 
eases in  the  offspring),  to  examine  the  apices  as  to 
height  and  air-contents.  Many  cases  of  clear  tuber- 
culosis in  children,  whose  parents  are  apparently 
healthy  and  have  never  been  seriously  sick,  will  be 
explained  by  such  a  cicatrized  apex  in  one  or  other  of 
the  parents.  If  we  inquire  more  closely  into  such 
cases  we  will  generally  obtain  some  useful  data  for 
the  anamnesis,  as,  for  example,  that  the  person  when 
young  suffered  for  a  long  time  with  "  catarrh,"  or 
used  to  spit  blood,  or  had  pleurisy  or  "  intermittent 
fever  which  quinine  didn't  help,"  etc. 

A  careful  examination  of  the  apex  is  also  very 
important  as  regards  the  question  oi  primary  laryngeal 
tuberculosis.  It  has  been  repeatedly  maintained  that 
the  tubercle  bacillus  may  gain  admission  through  the 
laryngeal  mucous  membrane  as  well  as  the  lungs. 
Cases  have  been  cited  where  tuberculosis  of  the  larynx 
existed  without  the  slightest  trace  of  it  being  found  in 
the  thorax.  I  have  seen,  however,  many  cases  which 
at  first  produced  the  impression  of  primary  laryngeal 
tuberculosis,  but  in  which  closer  investigation  of  the 
apices  showed  cicatricial  remains  of  older  processes. 
So  far  I  have  not  seen  any  really  convincing  case  of 
pure   primary  tuberculosis  of  the   larynx,  but,  on  the 


;  —  42  — 

contrary,  1  have  met  frequent  cases  of  sub-acute  or 
chronic  laryngeal  tuberculosis  joined  with  latent  or 
entirely  healed  tuberculosis  of  the  shrunken  apices. 


CHAPTER  II. 

SPUTUM— BACILLI- ELASTIC  FIBRES— MYELIN 
CELLS— HEMOPTYSIS. 

Since  Koch's  discovery,  the  microscopical  examina- 
tion of  the  sputum  holds  the  first  place  in  diagnosis. 
Formerly,  in  order  to  diagnose  the  process  of  decay, 
it  was  required  to  discover  histological  elements  of 
the  pulmonary  tissue  in  the  sputum.  However,  the 
demonstration  of  elastic  fibres  arranged  as  in  lung 
structure  shows  at  most  only  a  condition  of  disturb- 
ance, and  is  not  pathognostic  of  tuberculosis.  Koch's 
discovery  gave  to  the  microscopic  examination  of 
sputum  a  much  more  distinct  significance,  namely, 
where  puhnonary  tuberculosis  exists,  tubercle  bacilli  will 
be  found  in  the  expectoration.  Even  should  they  be 
scarce,  repeated  examinations  will  bring  some  to  light. 
It  may  to-day  be  stated  as  one  of  the  best  established 
diagnostic  axioms  that  where  tubercule  bacilli  are  found 
in  the  sputum,  tuberculosis  exists;  on  the  other  hand, 
that  where  pulmonary  tuberculosis  exists,  bacilli  will  ap- 
pear in  the  sputum;  and  finally,  that  in  lung  affections 
where  skilled  examinations  exhibit  no  tubercle  bacilli, 
tuberculosis  can  be  excluded.  At  present,  however, 
there  are  several  exceptions  to  these  propositions, 
namely,  acute  miliary  tuberculosis,  in  which  bacilli 
have  not  yet  been  demonstrated   in  the  sputum,  and 


—  44  — 
obsolete  apical  tuberculosis,  where  the  callous  con- 
nective tissue  has  completely  encapsulated  the  bacilli. 
Thus  we  see  the  great  importance  of  the  bacilli 
for  diagnosis.  A  single  morphological  element  de- 
cides it.  Still  we  must  bear  in  mind  the  fundamental 
axiom  of  diagnosis:  Never  base  a  diagnosis  on  any 
single  cause  but  always  on  the  totality  of  the  symptoms.  I 
do  not  mean  to  call  in  question  in  the  slightest  the 
pathognostic  importance  of  tubercle  bacilli  in  the 
sputum.  In  the  hands  of  an  expert  in  bacteriological 
investigation,  a  preparation  showing  bacilli  gives 
absolute  warrant  for  diagnosis.  But  the  investigator 
must  be  entirely  familiar  with  the  proper  method  of 
demonstrating  them.  Simple  as  is  the  method  in 
vogue  of  Ehrlich-Weigert  or  Ziehl-Neelsen,  the  search 
for  and  recognition  of  bacilli  require  the  same  ex- 
perience and  care  that  are  necessary  in  other  investi- 
gations, if  the  result  is  to  be  trustworthy.  An  error 
from  inexperience  is  here  more  serious,  because  it 
concerns  a  matter  in  itself  decisive  of  a  grave  diag- 
nosis. I  have  seen  strange  things  in  the  practice  of 
colleagues  who  though  otherwise  very  capable  had 
not  mastered  microscopical  technique  and  in  con- 
sequence made  wonderful  diagnoses  by  means  of  the 
microscope.  Physicians  should  be  very  cautious  in 
their  conclusions,  and  in  doubtful  cases  should  have 
their  results  verified  by  some  scientific  authority,  as  a 
pathological  or  clinical  institute.* 

*  See  Appendix  for   method   of   examining    sputum   for 
bacilli. — Tr, 


—  45   — 

We  now  approach  the  question  of  the  relation  be- 
tween the  number  of  bacilli  in  the  sputum  and  the 
pathological  changes  which  the  lungs  have  undergone. 
May  we  infer  favorable  changes  from  a  decrease  in 
their  number,  and  unfavorable  ones  from  their  in- 
crease ?  This  question  can  generally  be  answered  in 
the  affirmative.  Numerous  bacilli  in  the  sputum  de- 
note rapid  softening  and  usually  coincide  with  fever, 
night-sweats,  etc.;  few  bacilli,  on  the  contrary,  are 
found  in  chronic  tuberculosis  and  pertain  to  secretions 
from  cavities.  A  gradual  numerical  decrease  of 
bacilli  (for  example,  during  a  course  of  climatic  treat- 
ment) indicates  curative  changes  and  will  usually  be 
accompanied  by  corresponding  improvement  in  appe- 
tite and  weight,  freedom  from  fever,  cessation  of 
night-sweats,  etc.  There  are  some  exceptions  to  this 
general  statement.  Few  bacilli  are  found  in  progres- 
sive softening,  if  the  focus  of  softening  is  still  separate 
from  the  bronchi;  and  on  the  other  hand  numerous 
bacilli  appear  in  old  inactive  cavities  if  their  walls 
should  be  irritated,  for  example  by  any  external  agent, 
and  their  secretion  be  thereby  increased. 

Koch's  discovery  has  given  a  degree  of  certainty 
to  the  diagnosis  of  pulmonary  tuberculosis  that  can  be 
affirmed  of  but  few  diseases.  Furthermore,  this  cer- 
tainty that  tuberculosis  is  really  present  in  individual 
cases  has  improved  our  knowledge  of  its  curability. 
The  pessimistic  standpoint  of  the  old  school  has  been 
shaken  by  nothing  so  much    as  by    Koch's  doctrine 


-  46  - 

which  has  taught  us  to  recognize  many  apparently 
harmless  cirrhoses  of  the  lungs  as  really  tuberculous 
and  to  trace  out  their  cures.  It  is  consequently  not 
at  all  justifiable  to  declare  a  patient  lost  in  whose 
sputum  bacilli  are  discovered.  Rather  we  should  ap- 
proach the  treatment  of  tuberculosis  with  much 
greater  assurance,  because  our  knowledge  of  thera- 
peutic measures  has  been  so  extraordinarily  increased 
and  because  the  hope  (which  formerly  found  only 
timid  expression)  that  the  disease  could  be  really 
cured  has  been  fully  verified.  The  fact  that  this  cer- 
tainty of  diagnosis  may  be  had  at  the  very  beginning 
of  the  disease  has  given  greater  distinctness  to  thera- 
peutic indications  and  better  foundation  to  the  expec- 
tation of  cure. 

Finally,  we  are  able  (and  this  is  of  utmost  value) 
to  exclude  tuberculosis  in  chronic  lung  troubles  on 
account  of  the  continued  absence  of  bacilli  from  the 
sputum.  The  diagnosis  of  simple  chronic  inflamma- 
tion of  the  bronchi  and  pulmonary  tissue,  peribron- 
chitis nodosa,  anthracosis,  cirrhosis  and  bronchiectasis, 
pulmonary  syphilis  and  neoplasms  of  the  lungs  is  ren- 
dered easier  by  the  exclusion  of  tuberculosis;  indeed, 
in  many  cases  it  only  then  becomes  possible.  So  that 
the  clinical  investigation  of  these  obscure  pulmonary 
diseases  (for  example,  pulmonary  syphilis)  has  been 
directed  into  new  paths  by  the  clearing  up  of  the  sub- 
ject of  tuberculosis. 

I  shall  now  mention  some  other  things  which  are 


—  47  — 
found  in  the  microscopical  examination  of  the  sputum. 
Of  these  I  first  consider  elastic  fibres.  No  importance 
should  be  attached  to  single  elastic  fibres.  They  con- 
stitute a  pathognostic  sign  of  tuberculosis  only  when 
they  present  under  the  microscope  the  connection  and 
arrangement  which  they  have  in  pulmonary  tissue. 
This  hint  will  enable  us  to  avoid  errors  which  may 
arise  from  accidental  admixture  with  the  sputum  of 
bits  of  meat,  or  shreds  of  tendons  and  connective 
tissue  which  may  have  remained  caught  in  the  teeth. 
The  importance  of  elastic  fibres  when  found  in  the 
histological  arrangement  characteristic  of  lung  tissue 
is,  however,  always  great.  As  already  said,  they  indi- 
cate only  a  destruction  of  the  tissues;  but  when  tuber- 
cle bacilli  are  also  found  in  the  sputum,  it  speaks  for 
progressive  tuberculous  softening  and  against  a  sta- 
tionary condition.  To  distinguish  that  is  sometimes  of 
great  value. 

When  the  elastic  fibres  are  but  sparingly  present, 
the  search  for  them  requires  much  patience  and  per- 
severance. Fenwick's  method  is  recommended  as  the 
best.  This  consists  in  boiling  the  sputum  with  eighteen 
per  cent,  caustic  soda  and  then  mixing  it  with  three 
or  four  times  its  volume  of  water;  it  should  be  placed 
in  a  conical  glass  and  allowed  to  stand  for  twenty-four 
hours,  after  which  the  elastic  fibres  will  be  found  in 
the  deepest  layers  of  the  sediment. 

The  pigment  cells  and  myelin  cells,  which  are  also 
found  in  the  sputum  of  tuberculous   persons,  deserve 


-  48  — 

especial  notice.  In  1872,  in  his  paper  on  "Pneumonia^ 
Tuberculosis  and  Consumption,"  Buhl  expressed  the 
opinion  that  these  large  pigment-bearing  nucleated 
cells  and  myelin  cells  are,  if  numerous,  an  infallible 
sign  of  beginning  desquamative  pneumonia — the  initial 
inflammatory  stage  (according  to  him)  of  tuberculous 
phthisis,  and  that  the  quantity  of  myelin,  either  free 
or  enclosed  in  cells,  stands  in  a  direct  relation  to  the 
length  of  the  phthisical  process.  In  the  beginning, 
this  view  created  much  perplexity,  but  it  is  now,  I 
think,  generally  considered  as  refuted.  I  have  long 
since  observed  that  the  sputum  of  persons  who  are 
continually  in  a  hot,  dusty  atmosphere  contains  many 
large  pigment  cells,  fat  granules  and  myelin  forms, 
without  the  lungs  being  at  all  diseased.  I  have  also 
had  repeated  occasion  to  verify  after  death  the  in- 
tegrity of  the  lung  tissue  in  men  who  had  during  life 
plentifully  furnished  such  sputum.  They  are  mostly 
persons  whose  calling  or  circumstances  daily  expose 
them  to  a  hot,  smoky  atmosphere,  as  bakers,  smiths, 
bar-room  loungers  and  others. 

At  my  suggestion.  Dr.  Panizza  at  one  time  sub- 
jected the  whole  question  to  a  thorough  clinical  and 
experimental  investigation,  and  the  result  confirms  my 
view  as  to  the  unimportance  of  these  morphological 
elements  for  the  diagnosis  of  tuberculosis.  Myelin 
and  fat  granule  cells,  with  or  without  pigment  granules, 
are  found  in  all  lung  and  bronchial  affections,  but 
most  constantly  and  numerously  where  there  is  super- 


—  49  — 
ficial  irritation  of  the  breathing  surfaces,  such  as  is 
caused  by  a  heated,  smoky  atmosphere.  Of  five  hun- 
dred healthy  and  sick  men  whose  sputa  were  examined 
by  Panizza,  pigment-bearing  cells  and  myelin  forms 
were  found  in  eighty-six  per  cent,  of  the  healthy,  only 
the  sero-mucous  morning  sputum  being  examined. 
When  the  examination  was  limited  to  special  classes, 
as  smiths,  cabinet-makers,  cooks,  etc.,  an  abundance 
of  these  cells  was  found  in  ninety  per  cent,  of  them. 
Even  after  such  persons  had  been  in  the  hospital  for 
a  long  time  the  cells,  though  somewhat  decreased  in 
quantity,  did  not  entirely  disappear.  Panizza  was 
also  often  able  to  establish  the  integrity  of  the  lung 
tissue  in  some  of  the  patients  who  had  died  of  other 
diseases.  Consequently  the  occurrence  of  myelin  and 
pigment  in  the  sputum  must  be  considered  a  phenom- 
enon compatible  with  health;  though  when  very 
numerous  these  elements  indicate  in  general  an  irri- 
tated condition  of  the  breathing  surfaces. 

As  to  the  origin  of  myelin  and  myelin  cells, 
Panizza  was  led  by  his  researches  on  the  respiratory 
mucous  membrane  of  the  living  frog  to  the  view  that 
myelin  is  identical  with  mucm  which  is  insoluble  in 
water  but  swells  up  in  it.  According  to  him,  this 
mucin  is  a  secretion  of  the  beaker  cells  lying  between 
the  ciliated  epithelial  cells  and  it  is  poured  out  abun- 
dantly on  slight  irritation,  as,  for  example,  by  the  ad- 
mission of  water.  At  first  spherical  shaped,  it  presses 
by  amoeboid  movements  up  on  the  surface  and  seizes 


—  5°  — 
the  pigment  granules  which  are  lodged  there,  and  then, 
having  acquired  a  delicate  enclosing  membrane,  it  is 
pushed  outwards  as  myelin  and   pigment  cells  by  the 
movement  of  the  cilia. 

It  is  not  to  be  disputed  that  where  there  is  con- 
tinual irritation  of  the  respiratory  apparatus,  as  in 
trades  associated  with  dusty  atmospheres,  the  alveolar 
epithelial  cells  may  also  take  up  pigment  and  appear 
in  the  sputum  as  large  pigment-bearing  myelin  cells. 
But  there  is  no  conclusive  reason  for  ascribing  all 
such  elements  in  the  expectoration  to  the  prolifera- 
ting alveolar  epithelium.  At  any  rate,  it  is  much 
easier  to  suppose  that  the  largest  part  of  the  dust 
particles  remain  clinging  to  the  surface  of  the  mucous 
membrane  and  are  there  taken  up  by  cellular  elements 
or  elements  which  later  receive  the  cell  form. 

To  be  sure,  this  does  not  settle  the  very  interest- 
ing question  of  the  origin  of  pigment-bearing  and 
myelin  cells.  That  question,  and  in  fact  the  entire 
subject  of  bronchial  secretion  and  expectoration,  need 
further  investigation  and  elucidation.  I  have  been 
constrained,  however,  to  show  that  the  presence  in  the 
sputum  of  abundant  pigment-bearing  and  myelin  cells 
and  free  myelin  has  no  pathognostic  significance  for 
pulmonary  tuberculosis;  but  that  it  is  to  be  considered 
in  a  general  way  as  an  indication  of  an  irritated  con- 
dition of  the  breathing  surfaces. 

Some  remarks  may  be  here  added  on  hemoptysis. 
It  is  to  be  considered    as   established  that   the  first 


—  51   — 

hemorrhage  in  tuberculosis  does  not  come  from 
healthy  lung  tissue  but  from  diseased  lobules;  and  the 
view  that  a  primary  hemorrhage  may  start  up  phthisis 
can  be  considered  as  definitely  set  aside.  The  patho- 
logical conditions  in  a  tuberculous  lung  which  lead  to 
hemorrhage  may  be  very  different.  From  a  clinical 
standpoint  I  would  distinguish  two  principal  classes: 
First,  hemorrhages  which  are  due  to  progressive 
changes  and  above  all  to  softening  consequent  on 
coagulation  necrosis;  and  secondly,  such  as  arise  from 
a  pronounced  retrograde  tendency  of  the  local  affec- 
tion. Whilst  hemoptysis  at  the  beginning  of  tuber- 
culosis and  at  the  advent  of  secondary  outbreaks  is 
serious,  its  significance,  even  though  frequently  re- 
peated, is  very  slight  when  there  is  a  decided  tend- 
ency to  healing.  In  the  former  case,  softening  and 
decay  of  the  tissue  is  the  essential  cause;  in  the  latter 
on  the  contrary,  the  bleeding  is  due  to  the  disturb- 
ance of  the  circulation  caused  by  the  cirrhotic  shrink- 
age of  the  tissues  and  to  the  most  trifling  changes  in 
the  walls  of  cavities.  From  this  point  of  view,  one 
may  say  with  some  degree  of  authority  that  habitual 
blood-spitters  are  not  the  worst  cases  for  treatment, 
but  rather  that  they  belong  to  a  favorable  class,  pro- 
vided, however,  that  there  is  a  general  retrograde 
tendency. 


CHAPTER  III. 

FEVER— IDIO-MUSCULAR    TETANUS— CONTRAC- 
TION   WAVES. 

Since  the  thermometer  has  come  into  use  as  an 
indispensable  domestic  guide,  at  least  among  all  half- 
way cultivated  families,  we  are  pretty  well  informed 
as  to  the  course  of  fever  in  tuberculosis.  Sick  people 
generally  take  their  temperature  more  frequently  than 
is  necessary.  Every  slight  disturbance,  every  discom- 
fort causes  a  resort  to  the  thermometer.  That  is  of 
advantage  to  medical  observation,  so  long  as  the  dis- 
ease has  not  progressed  very  far;  but  in  the  later 
stages  it  is  bad,  inasmuch  as  the  permanence  of  high 
temperature  produces  a  depressing  effect  on  the  pa- 
tient. Hence  it  is  advisable,  in  advanced  stages,  to 
limit  or  entirely  suspend  the  taking  of  temperature. 

The  significance  of  fever  in  tuberculosis  is  always 
very  great.  Constant  high  temperature  denotes  a 
progress  of  the  bacillary  and  inflammatory  process; 
whilst  continued  apyrexia  corresponds  to  a  retro- 
gressive tendency  of  the  disease.  The  cause  of  the 
fever  is  always  to  be  sought  for  in  the  local  changes: 
on  one  hand,  in  the  multiplication  of  bacilli,  the  re- 
active inflammation  of  the  lung  tissue  and  in  the  fever- 
exciting  products  of  both;  on  the  other  hand,  very 
probably  also  in  the  absorption  of  products  of   decay 


—  53  — 
from  the  focus  of  softening  and  in  the  chemical  pro- 
ducts of  secondary  colonies  of  cocci,  about  the  bear- 
ing of  which  on  local  and  general  disturbance  in  pul- 
monary tuberculosis,  we  in  fact  know  very  little. 
Viewed  in  their  extremes,  we  may  compare  the  con- 
tinuous fever  of  acute  infiltrations  with  the  fever  of 
pneumonia,  and  the  erratic  or  regularly  occurring  ex- 
acerbations of  the  late  stages  with  that  of  septic  in- 
fection. Between  these  extremes  lie  many  inter- 
mediate forms,  among  which  the  slight  febrile  excite- 
ment, which  often  lasts  for  months,  is  least  clearly  due 
to  the  local  changes.  In  general,  we  may  observe  in 
this  disease,  just  as  in  severe  fevers,  a  remission 
entirely  or  almost  down  to  normal  in  the  morning  and 
an  exacerbation  towards  mid-day  or  in  the  afternoon. 
Leaving  aside  the  higher  degrees  of  absorption 
fever,  the  fever  curve  of  tuberculosis  generally  cor- 
responds to  the  curve  of  protracted  acute  and  sub- 
acute infectious  fevers;  but  there  is  not  the  same 
regularity  of  movement,  such  as  is  observed,  for  ex- 
ample, in  typhus.  This  is  best  shown  by  hourly  ob- 
servations continued  during  the  twenty-four  hours. 
Just  as  in  the  curve  of  typhoid  fever,  so  here  double- 
crested  curves  are  usually  marked,  corresponding  to 
the  late  forenoon  and  the  afternoon,  whilst  after  six 
o'clock  p.  M.  the  temperature  declines  to  the  morning 
minimum.  In  many  cases,  the  twenty-four  hours' 
curve  shows  only  one  crest  in  the  afternoon,  or  more 
rarely   in    the  forenoon.       Triple-peaked    curves  are 


—   54   — 

found  very  seldom,  and  then  one  of  the  crests  corre- 
sponds with  midnight. 

The  more  the  symptoms  are  those  of  absorption 
fever,  the  greater  will  be  the  difference  between  the 
temperature  of  the  remission  and  the  exacerbation. 
The  higher  the  latter,  the  lower  the  former — not  only 
down  to  normal,  but  often  a  degree  or  two  below  it. 
To  explain  this  access  of  fever,  we  must  suppose,  as 
in  the  septic  fevers,  that  either  the  absorption  of  pyro- 
genic  matter  into  the  circulation  occurs  with  some 
regularity  and  calls  forth  an  explosive  reaction  of  the 
organism,  or  else  that  as  soon  as  it  has  sufficiently 
accumulated  in  the  blood,  it  causes  an  excitation  of 
the  nerve  centre  for  temperature  and  produces  a  sort 
of  cumulative  effect.  Although,  as  appears  from  what 
I  have  said,  we  cannot  assign  a  distinctive  type  to  the 
fever  of  tuberculosis,  it  is  still  worth  while  to  impress 
on  our  minds  the  usual  manner  of  its  course. 

I  wish  next  to  speak  of  an  interesting  phenome- 
non which  was  long  held  to  have  a  diagnostic  value, 
and  which  occurs  usually,  if  not  exclusively,  in  tuber- 
culous phthisis.  I  mean  the  so-called  idi'o-muscular 
contraction*  which  owes   its  origin  to    the    abnormal 


*  From  the  Greek  z'iSzoS,  peculiar.  This  phenomenon, 
first  observed  by  Graves  and  Stokes,  was  described  by  Tait,  in 
the  Dublin  Journal  of  Medical  Sciences  (Vol.  LI  I,  p.  316),  and 
called  by  him  "  Myoidema."  To  elicit  it,  the  percussion  must 
be  immediate,  /.  <■. ,  without  the  interposition  of  plessimeter  or 
finger. — Tr. 


—  55  — 
mechanical  irritability  of  the  emaciated  muscles.  If 
we^strike  firmly  with  the  percussion  hammer  or  the 
tip  of  the  finger  on  the  pectoral  muscle  of  an  emaci- 
ated consumptive  near  the  sternum,  we  do  not  get 
that  rapid  movement  through  the  extent  of  the  fasci- 
culus of  the  muscle  which  occurs  in  health,  but  instead 
a.  rather  hard  muscular  tumor,  corresponding  to  the 
size  and  form  of  the  percussing  body,  appears  and 
quickly  disappears.  This  brief  circumscribed  tetanus 
may  be  combined  with  the  normal  muscular  move- 
ment, but  such  a  combination  is  not  constant.  It  may 
be  simultaneously  elicited  at  different  parts  of  the 
muscle,  or  even  of  the  same  fasciculus,  by  using  all 
the  fingers  in  percussion. 

In  many  consumptives,  besides  this  idio-muscular 
tetanus,  another  notable  phenomenon  occurs.  When 
the  tumor  forms,  very  superficial  and  delicate  contrac- 
tion 7vaves  pass  from  it  on  each  side  across  the  muscle. 
They  run  perpendicular  to  the  long  axis  of  the  fasci- 
culus and  mark  the  extent  of  the  irritation  or  force 
applied.  They  are  best  seen  if  one  draw  the  handle 
of  the  hammer  firmly  and  quickly  across  the  muscle 
parallel  to  the  sternum.  Two  delicate  waves,  cor- 
responding in  width  to  the  length  of  the  streak,  are 
formed,  one  moving  towards  the  sternum  and  the 
other  towards  the  humerus,  and  both  gradually  de- 
creasing in  size.  If  two  or  more  such  lines  are  drawn 
parallel  to  one  another,  each  will  give  off  two  lateral 
waves;  and  it  is  noticed    on   close    observation    that, 


-  56  - 
when  any  two  opposing  waves  meet,  they  do  not  die 
out  but  they  pass  on,  one  over  the  other.  The  more 
advanced  the  phthisis  and  the  more  wasted  the  adipose 
tissue  and  muscles,  the  more  clearly  and  constantly 
will  this  phenomenon  be  elicited. 

The  phenomenon  of  myoidema  was  long  known 
to  physiologists,  but  frequent  observation  of  it  in  con- 
sumptives first  led  the  English  surgeon,  Lawson  Tait, 
to  think  it  was  a  pathognostic  sign  of  phthisis,  and  in 
fact  of  the  softening  stage.  Later  observers  have 
verified  its  occurrence  in  advanced  phthisis  without, 
however,  giving  full  assent  to  Tait's  opinion  of  its 
pathognostic  significance.  In  conjunction  with  two  of 
my  pupils,  Dr.  von  Millbacher  and.  Dr.  Stadelmann,  I 
have  subjected  the  matter  to  a  close  investigation. 
Our  conclusions  were  briefly  the  following: 

1.  The  idio-muscular  convulsion  occurs  only 
when  the  adipose  tissue  is  completely  wasted  and  the 
muscles  are  extremely  emaciated.  It  can  consequently 
be  elicited  in  all  patients  in  whom  these  conditions 
are  verified  and  of  course  especially  in  consumptives 
in  whom  emaciation  is  usually  very  great.  We  found 
it  to  occur  in  other  diseases  which  cause  great  emacia- 
tion, as  in  the  fourth  or  fifth  week  of  abdominal 
typhus,  in  cases  of  neoplasms,  etc. 

2.  For  demonstrating  the  phenomenon,  only 
those  muscles  are  suitable  which  lie  upon  osseous 
structures  against  which  they  can  be  firmly  com- 
pressed by  the  stroke.     The   muscle  best  adapted   is 


—  57  — 
the  broad   pectoralis  major,  but  we  found  it  in   other 
muscles  with  a  hard  back-ground,    as,    for   example, 
thesupra-spinatus,  deltoideus,  extensor  digitorum  com- 
munis, tibialis  anticus,  etc. 

3.  We  succeeded  a  few  times  in  eliciting  a  weak 
tumor  formation  in  men  apparently  healthy  but  very 
emaciated. 

4.  The  histological  changes  on  which  the  phe- 
nomenon depends  are  a  high  degree  of  atrophy  of  the 
adipose  and  cutis,  and  simple  atrophy  and  fatty  de- 
generation of  the  primitive  fasciculus.  But  also  pro- 
liferative changes  in  the  internal  perimysium  and  con- 
nective tissue,  as  well  as  proliferation  of  nuclei  in 
the  sheaths  of  smaller  vessels  and  thickening  of  the 
adventitia  of  larger  vessels,  play  a  part  in  it.  On  post 
mortem  examinations,  von  Millbacher  found  the  "  tied 
fasciculi  of  Fraenkel "  {umschniirten  Biindel)  abund- 
ant in  muscles  which  during  life  had  exhibited  the 
phenomenon  in  a  marked  degree.  Besides  prolifera- 
tion of  the  nuclei  in  the  connective  tissue  and  vascular 
sheaths,  he  always  found,  in  the  neighborhood  of  ves- 
sels with  thickened  walls,  fasciculi  bound  around 
either  partly  or  completely  with  connective  tissue. 
Often,  in  fact,  the  proliferated  connective  tissue 
sheaths  of  both  were  directly  proportioned  to  each 
other. 

5.  These  anatomical  changes  impel  us  to  rank 
this  abnormal  muscular  irritability  (which  is  obviously 
independent   of  nerve   influence)    with   the  excessive 


-  58  - 

irritability  of  muscles  entirely  withdrawn  from  nerve 
influence  by  cutting  or  degeneration  of  the  nerves  and 
involved  in  atrophic  and  interstitial  proliferative 
changes.  However,  the  two  cases  are  essentially 
different.  In  motor  paralysis,  the  nerves  are  degen- 
erated down  to  their  end-plates;  here  they  are  well 
preserved.  In  the  former,  the  muscles  are  not  subiect 
to  the  will;  here  they  are  capable  of  function,  even 
though  they  may  be  weak.  There  the  reaction  of 
muscles  and  nerves  to  the  electric  current  changes 
with  the  succession  of  appearances  which  represent 
the  reaction  of  degeneration,"^  and  the  entire  muscle, 
or,  at  least,  entire  fasciculi  of  it,  slowly  respond  with- 
out forming  a  contraction  tumor;  here  only  the  part 
of  the  muscle  which  is  directly  affected  undergoes  a 
brief  tetanus  and  sends  out  superficial  waves,  a  thing 
that  never  occurs  in  the  reaction  of  degeneration  in 
excessively  irritable  muscles. 

6.  Though  the  analogy  between  the  reaction  of 
simple  emaciated  muscles  and  that  of  paralyzed  mus- 
cles is  not  tenable,  we  do  find  an  important  relation- 
ship between  the  phenomenon  under  consideration  and 
the  physiological  condition  of  exhausted  or  moribund 
muscle.     Years  ago  Schiff  noticed  in  the  exhausted 


*  The  reaction  of  degeneration,  as  described  by  Erb,  con- 
sists in  the  loss  of  both  galvanic  and  faradic  irritability  by  the 
nerves,  whilst  the  muscles  lose  only  faradic  irritability,  but 
their  galvanic  irritability  is  always  changed  in  quality  and 
sometimes  increased. — Tr. 


—  59  — 
or  dying  muscles  of  mammals  precisely  the  same  ap- 
pearances which  we  observe  in  the  emaciated  muscles 
of  consumptives.  There  can  consequently  be  scarcely 
a  doubt  that  in  the  atrophied  muscles  of  consumptives 
we  have  to  deal  with  a  phenomenon  of  exhaustion  and 
dissolution  which  occurs  the  more  readily,  the  more 
atrophied  the  external  tissues  are. 

Though  this  does  not  explain  the  intimate  changes 
in  the  disease,  we  are  justified  by  this  physiological 
parallel,  as  well  as  by  clinical  observation,  in  conclud- 
ing that  this  idio-muscular  contraction  has  nothing  to 
do  with  tuberculosis  itself;  that  it  is  merely  a  phe- 
nomenon connected  with  emaciation  and  going  hand 
in  hand  with  the  general  waste  of  the  tissues;  and 
that  consequently  it  has  no  diagnostic  significance. 


CHAPTER  IV. 

VITALCAPACITYOFTHE  LUNGS— BODY  WEIGHT. 

I  will  next  briefly  refer  to  two  appliances  which 
are  valuable  for  diagnosis,  for  the  continued  study  of 
a  case,  and  for  determining  the  line  of  treatment,  and 
which  I  think  have  not  been  sufficiently  appreciated 
by  physicians,  namely,  the  spirometer  and  the  scales. 

In  speaking  of  the  spirofneter  I  shall  not  consider 
the  physiological  side  of  the  subject  of  lung  capacity 
but  shall  limit  myself  to  some  practical  questions. 

Spirometry  is  seldom  used  by  physicians,  partly 
because  it  is  thought  that  its  results  depend  too  much 
on  the  patient's  skill  and  practice  to  have  exact  and 
constant  value,  and  partly  because  we  have  no  ab- 
solute standard  of  vital  capacity  in  health.  These 
views,  however,  are  not  verified  in  practice.  There 
are  of  course  many  clumsy  men,  especially  in  the 
lower  walks  of  life,  who  are  unsuited  for  examinations 
in  which  they  themselves  must  co-operate  with  the 
physician.  But  their  number  is  very  much  reduced  if 
pains  are  taken  to  instruct  them.  In  my  hospital 
wards  we  have  by  patience  and  practice  generally  suc- 
ceeded in  making  spirometric  measurements;  though 
we  also  noted  that  clumsiness  in  this  matter  prevails 
more  among  women  than  among  men. 

As  regards  the  second  objection,  namely  the  im- 
possibility  of  assigning   an  absolute  value    to    vital 


—  6i    — 

capacity  in  health,  it  is  true  that  such  an  impossibility 
exists  because  the  amount  of  vital  capacity  depends 
on  very  different  factors.  Among  these,  stature  is  the 
most  important  inasmuch  as  a  constant  proportion 
exists  between  vital  capacity  and  size  of  body,  though 
different  in  the  two  sexes.  The  other  factors,  for  ex- 
ample, circumference  of  chest,  length  of  flanks,  weight, 
age,  trades,  etc.,  do  not  affect  vital  capacity  to  such  an 
extent  as  stature.  Accidental  factors,  such  as  a  full 
stomach,  intestinal  flatus,  position  of  body,  etc.,  can 
always  be  removed.  Guided  by  four  years'  experience, 
I  advise  that  only  the  relation  between  the  volume  of 
expired  air  and  the  stature  should  be  taken  as  a 
standard  in  estimating  vital  capacity.  Both  can  be 
easily  ascertained  and  the  proportion  between  them 
needs  only  a  moment's  calculation.  Hutchinson,  the 
inventor  of  the  spirometer,  and  Winternich  calculated 
the  vital  capacity  in  units  of  linear  measurement,  that 
is  in  inches  and  centimeters. 

I  have  endeavored  to  establish  a  sort  of  boundary 
line  between  normal  and  sub-normal  vital  capacity, 
and  I  have  found  that  the  minimum  proportion  in 
health  is  one  to  twenty  for  men  (/.  e.  one  centimeter  of 
height  to  twenty  cubic  centimeters  of  vital  capacity) 
and  one  to  seventeen  for  women.*  These  limits  have 
of  course  only  an  approximate  value,  but  that  does  not 


*  Denoting  height  in  inches  and  capacity  in  cubic  inches, 
the  proportion  will  be  for  men  i  to  3,  and  for  women  i  to  2.6 
— Tr. 


—  6a  — 

much  matter  in  practice  because  in  the  pathological 
conditions  which  come  before  us  we  have  usually  to 
deal  with  wide  variations.  Furthermore,  the  chief 
value  of  spirometry  does  not  consist  in  absolutely 
determining  the  vital  capacity  but  rather  in  noting 
the  variations  of  vital  capacity  in  the  same  individual 
during  a  lengthened  period  of  time.  Consequently, 
the  procedure  is  less  valuable  for  primary  diagnosis 
than  for  noting  changes  in  the  respiratory  function 
during  a  course  of  observation  and  treatment. 

The  pathological  conditions  of  the  respiratory 
organs  which  diminish  vital  capacity  are  very  numer- 
ous. They  include  all  acute  and  chronic  affections  of 
the  lungs,  pleurae,  heart  and  thorax,  and  affections  of 
the  abdominal  viscera  which  narrow  the  thoracic 
space.  Hence  spirometry  serves  only  to  corrob- 
orate the  results  of  other  methods  of  examination. 
Among  the  changes  which  most  influence  vital  capa- 
city I  may  name  (in  addition  to  pulmonary  tuber- 
culosis) adhesions  of  the  pleurae  following  pleuritis,  ad- 
hesion and  lifting  of  the  diaphragm,  pulmonary  em- 
physema, cirrhosis  of  the  lungs  and  bronchitis. 

We  may  then  say  in  general:  When  the  propor- 
tion of  stature  to  vital  capacity  falls  below  one  to 
twenty  in  a  man  or  one  to  seventeen  in  a  woman,  we 
may  infer  a  considerable  disturbance  of  the  respira- 
tory organs,  the  nature  of  which  is  to  be  determined 
by  other  methods;  if,  however,  we  should  find  a  pro- 
portion of,  say,  one  to  twenty-five  in  a  man   or  one  to 


twenty-two  in  a  woman,  such  a  disturbance  would  be 
a  priori  improbable. 

The  absolute  value  of  these  data  may  be  illustrated 
by  an  example.  An  unusually  tall  and  slender  youth 
of  twenty-five  years,  the  son  of  a  father  who  had  died 
of  phthisis,  was  brought  to  me  by  his  anxious  mother 
to  learn  whether  his  emaciation, 'pallor  and  sickly  ap- 
pearance were  due  to  aay  pulmonary  trouble.  The 
physical  examination  resulted  negatively.  Still, 
isolated  rales  in  the  upper  lobes  in  connection  with 
the  anaemia,  the  "paralytic  thorax,"  the  poorly  de- 
veloped muscles,  the  cardiac  palpitation,  and  the  tend- 
ency to  perspire  at  any  vigorous  muscular  effort,  made 
the  case  suspicious  as  one  of  quickly  developing  tuber- 
culosis. The  spirometric  examination  gave  for  a 
height  of  1 86  cm.  (74  inches)  a  vital  capacity  of  5,000 
ccm.  (305  cubic  inches),  or  a  proportion  of  i  to  27 
(i  to  4.1  in  inches  and  cubic  inches).  This  rendered 
the  exclusion  of  tuberculosis  more  certain  and  gave 
definiteness  to  the  therapeutic  indications.  Three 
months  later  the  vital  capacity  was  found  to  be  the 
same,  and  the  measures  adopted  in  the  interim 
(shower-baths,  sea-baths,  mountain  climbing  and 
bodily  exercise)  had  produced  a  gratifying  effect  on 
the  general  nutrition,  the  muscular  strength,  the  color 
of  the  skin  and  mucous  membrane,  and  also  on  the 
cardiac  palpitation. 

A  contrast  to  the  above  is  furnished  in  the  follow- 
ing case.     A  young  man  belonging  to  an   apparently 


-  64  - 

healthy  family  had  not  long  ago  an  attack  of  hemop- 
tysis, and  since  then  he  has  had  a  dry  cough  without 
expectoration.  Otherwise  he  seems  not  much  affected. 
Physical  examination  showed  a  scarcely  appreciable 
difference  in  the  apices  and  at  the  same  place  isolated 
rales  and  prolonged  respiration.  The  pleurae  were 
free,  and  the  position  of  the  diaphragm  and  the  move- 
ment of  the  edges  of  the  lungs  normal.  The  spirom- 
eter gave  for  a  stature  of  175  cm.  (or  68  inches),  a 
constant  vital  capacity  of  3,200  ccm.  (or  195  cubic 
inches),  or  a  proportion  of  i  to  18  (i  to  2.8).  This 
made  the  diagnosis  of  beginning  tuberculosis  pretty 
certain.  A  few  months  later  we  found  tubercle  bacilli 
in  his  sputum. 

The  relative  value  of  spirometry  is  shown  best  in 
cases  where  definite  changes  are  noted  in  the  respira- 
tory apparatus  and  where  repeated  tests  are  made  dur- 
ing a  long  course  of  observation. 

If  even  a  slight  increase  in  vital  capacity  appear 
during  a  course  of  climatic  or  other  treatment,  it  is 
valuable  for  prognosis  and  will  be  usually  found  to 
correspond  with  improvement  in  other  directions. 
But  a  rapid  or  slow  decrease  is  an  ominous  confirma- 
tion of  other  unfavorable  appearances.  I  will  also 
cite  a  case  in  illustration. 

In  a  young  woman,  twenty-eight  years  of  age,  with 
an  inherited  weak  constitution  (tuberculosis  was  shown 
only  in  her  maternal  uncles  and  aunts),  an  undoubted 
tuberculosis  of  the  apices,  bacilli  in  the  sputum,  etc.,. 


-65  - 

the  spirometric  test  gave  a  constant  vital  capacity 
of  2600  ccm.  (128  cu.  in.)  for  a  height  of  160  cm.  (63 
inches),  that  is  a  proportion  of  i  to  15.6  (i  to  2.5). 
She  passed  the  winter  at  Meran,  where  she  was  almost 
entirely  free  from  fever,  and  where  she  took  regular 
exercise  in  climbing.  Her  appetite  improved;  she 
gained  6  kgrms.  (13  lbs.)  in  weight,  and  the  next  year 
possessed  a  constant  vital  capacity  of  2700  ccm.  (164 
cu.  in.),  that  is  a  proportion  of  i  to  17  (i  to  2.6). 
Four  years  have  since  passed  and  she  is  still  healthy, 
the  dullness  over  the  apices  has  almost  completely 
disappeared,  and  bacilli  are  no  longer  found  in  the 
sputum. 

Of  course  I  could  furnish  a  far  greater  number 
of  cases  which  contrast  with  this  favorable  one  and  in 
which  the  vital  capacity  steadily  decreased.  The  de- 
crease may  be  very  great,  partly  through  progressive 
infiltration,  partly  through  fever,  muscular  weakness, 
etc.  Often  in  advanced  cases  we  do  not  get  a  higher 
proportion  than  i  to  8  (or  i  to  1.2).  Nevertheless, 
where  vital  capacity  rapidly  and  notably  diminishes, 
we  should  not  infer  that  the  tuberculous  process  is 
spreading  unless  the  physical  examination  also  indi- 
cates it,  and  unless  we  can  also  exclude  diffuse  bron- 
chitis, pleuritis,  high  fever,  etc. 

The  scales  are  another  apparatus  valuable  as  an 
aid  in  diagnosis  and  prognosis.  They  have  been  long 
used  in  hospitals  and  health  resorts  for  diseases  of 
the  chest,  but  seem  to  be  but  little  employed  in  private 

6   EB 


—  66  —     . 

practice.  The  knowledge  of  the  patient's  weight  has 
a  relative,  not  an  absolute  value.  Abstracting  from 
the  extreme  loss  of  weight  which  occurs  in  the  last 
stage  of  consumption,  we  would  be  still  less  justified 
in  making  our  diagnosis  merely  from  the  fact  that  a 
patient  weighs  50  or  70  kilograms  (i  10  or  154  lbs.)  than 
we  would  be  from  a  knowledge  of  his  absolute 
vital  capacity.  In  the  latter  case  we  have  at  least  the 
stature  with  which  to  compare  the  volume  of  expired 
air.  The  size  of  the  body  cannot,  however,  serve  as  a 
standard  by  which  to  judge  whether  the  average 
weight  is  normal  or  abnormal,  for  there  are  people 
who  have  diseased  chests  and  whose  weight  is  consid- 
erable on  account  of  their  large  bones,  and,  on  the 
other  hand,  there  are  slender  delicate  persons  who  are 
entirely  healthy  in  spite  of  light  weight.  Hence, 
weight  has  no  absolute  worth  for  diagnosing  or  ex- 
cluding tuberculosis,  except  in  so  far  as  its  variations 
upwards  or  downwards  may  speak  for  or  against  the 
supposition  of  that  disease. 

But  weight  becomes  an  useful  guide  when  it  is 
tested  at  regular  intervals  in  a  patient,  as  is  done  in 
sanitariums  for  chest  diseases  and  in  many  hospitals. 
After  the  diagnosis  of  tuberculosis  has  been  settled, 
the  scales  will  inform  us  whether  the  process  is  ad- 
vancing or  receding,  whether  fever  is  present  or  not, 
and  whether  the  assimilation  of  food  is  sufficient. 

Even  the  maintenance  of  a  steady  weight,  after 
having  recouped  a  previous  loss,  is  a  favorable  sign  as 


-  67   - 

it  probably  speaks  against  a  progressive  tendency  of 
the  disease.  Steady  loss  of  weight  is  always  a  bad 
omen,  and  worse  in  proportion  to  its  rapidity,  for  it 
shows  that  the  general  economy  is  breaking  down 
under  the  iniiuence  of  the  fever.  On  the  contrary  a 
steady  even  though  slow  increase,  especially  in  con- 
nection with  other  local  and  general  signs  of  improve- 
ment, indicates  a  disappearance  of  the  fever  and  a 
better  condition  of  the  appetite  and  assimilation.  I 
need  scarcely  say  that  no  physician  will  be  misled  by 
an  increase  of  weight  produced  by  oedema  of  the 
limbs.  Thus,  if  the  patient  were  in  the  country  or  at 
a  health  resort,  the  scales  wpuld  keep  the  family  phy- 
sician informed  as  to  the  course  of  events  in  the  same 
way  that  the  spirometer  would.  Every  decrease  of 
weight  below  the  equilibrium  warns  the  patient  that 
something  is  wrong  and  causes  him  to  seek  the  advice 
of  his  physician.  On  the  other  hand,  every  increase 
in  weight  tells  him  that  his  condition  is  satisfactory, 
increases  his  confidence  in  his  treatment  and  strength- 
ens his  fidelity  in  following  it.  Tabulated  or  graphic 
statements  of  the  regular  weighings  are  of  great  inter- 
est to  the  physician  and  enable  him  and  the  relatives, 
even  when  the  patient  is  at  a  distance,  to  form  a 
pretty  correct  judgment  as  to  the  course  of  the  treat- 
ment. The  record  of  weighings  sent  by. the  patient  is 
a  sort  of  supervising  report  on  the  issue  of  the  thera- 
peutic efforts. 

The  above  points  are  all  important,  and  deserve 


—  68  — 

the  notice  and  study  of  the  readers.  Every  physician 
knows  how  helpful,  nay  necessary,  an  exact  diagnosis 
is  in  the  beginning  of  tuberculosis.  Here  as  else- 
where is  true  that  memorable  saying  of  Van  Swieten: 
"Qui  bene  diagnoscit,  bene  medebitur."* 


*A  correct  diagnosis  is  half  the  cure.     Literally,  he  who 
diagnoses  correctly  will  treat  well. — Tr. 


PART   THIRD. 


The  Ther/peutics  of  Pulmonary  Tuberculosis 


CHAPTER  I. 

PROPHYLACTIC       TREATMENT  —    HYGIENE  — 

CHOICE    OF   EMPLOYMENT— PRECAUTIONS 

AGAINST  CONTAGION— HYDROTHERAPY. 

The  discovery  of  the  bacilli  as  the  cause  of  tuber- 
culosis has  given  us  a  new  standpoint  for  its  treat- 
ment, but  so  far  has  had  no  other  important  result. 
The  first  thought  was  of  course  to  direct  all  thera- 
peutic efforts  against  them,  and  the  hope  was  ex- 
pressed by  many  that  some  remedy  might  be  dis- 
covered which  would,  without  injuring  the  body,  limit 
or  destroy  their  growth  or  vitality.  This  hope  of 
sanguine  investigators  has  not  yet  been  fulfilled,  and 
there  is  but  little  prospect  that  it  will  ever  be  realized. 
However,  modern  medicine  teaches  more  clearly  than 
ever  before  that  one  should  not  play  the  prophet,  and 
consequently  I  shall  not  disturb  with  doubts  the  hopes 
of  those  who  look  for  the  ultimate  extinction  of  tuber- 
culosis in  the  human  race.  Though  we  have  no 
specific  remedy  for  the  disease,  we  can  still  do  much 


—   70  — 

for  its  treatment,  especially  in  the  domain  of  dietetics, 
by  an  intelligent  and  well-planned  manner  of  living 
adapted  to  the  needs  of  the  individual  constitution. 

I  will  take  as  the  starting  point  of  my  remarks  an 
expression  of  Graves,  cited  by  Hermann  Weber:  "  It 
would  be  a  great  help  if  we  knew  how  to  make  a  per- 
son consumptive,  for  by  pursuing  the  opposite  course 
we  would  be  able  to  prevent  phthisis."  The  desire 
expressed  in  these  words  has  been  fulfilled  by  modern 
research,  the  real  cause  [materia  peccans)  has  been 
laid  bare,  and  the  conditions  which  favor  its  acquisi- 
tion have  been  recognized.  An  abundance  of  facts 
and  observations  have  been  accumulated  concerning 
the  causes  which  chiefly  favor  the  development  of  the 
disease,  whether  an  hereditary  tendency  be  present  or 
not.  I  have  already  described  these  causes  in  Part 
First,  and  shall  now  limit  myself  to  designating  the 
points  of  view  to  which  their  consideration  necessarily 
gives  rise.  I  shall  begin  with  the  observations  made 
there,  concerning  the  development  of  tuberculosis  in 
healthy  inmates  of  prisons,  convents  and  hospitals. 
The  Sisters  of  Charity,  whom  we  see  all  day  long  in 
our  hospital  wards  going  about  their  blessed  work  with 
utmost  zeal  and  devoted  self-sacrifice,  show  us  very 
clearly  how  tuberculosis  is  acquired  and  what  injurious 
influences  favor  its  development.  The  continual 
breathing  of  confined  air,  little  or  no  outdoor  move- 
ment, much  work,  monotonous  diet,  little  recreation 
and  much  night-watching  are  the  principal  causes.    Ex- 


—   71    — 

perience  also  teaches  us  that  mental  agitation,  spiritual 
struggles,  cares,  etc.,  contribute  to  diminish  the  body's 
power  of  resistance  to  the  disease. 

How  does  the  disease  develop  ?  What  precur- 
sory symptoms  herald  it  ?  Here,  as  among  the 
prisoners  described  by  Baer,  the  beginnings  are 
scarcely  noticeable.  We  find  rather  a  picture  of 
anaemia  with  muscular  weakness  and  anorexia.  Cough 
and  impaired  respiration  are  not  necessarily  present. 
Yet  the  physical  examination  will  show  infiltration. 
Baer  found  such  lingering  infiltrations,  followed  by 
rapid  decay,  in  prisoners  subjected  for  a  long  time  to 
unaccustomed  hard  labor  or  much  penal  dieting,  or  to 
the  influence  of  great  grief  or  deep  sorrow. 

In  marking  out  a  line  of  prophylactic  treatment, 
we  must  bear  in  mind  those  conditions  which  favor 
the  development  of  the  disease.  They  show  us  clearly 
what  must  be  avoided.  Instead  of  sitting  in  a  room, 
there  must  be  outdoor  movement;  instead  of  straining 
and  incessant  action  in  a  confined  place,  there  must 
be  regular  but  not  excessive  outdoor  muscular  work, 
with  intervals  of  rest;  instead  of  limited  diet,  there 
must  be  good  and  varied  food  corresponding  to  the 
work  and  consisting  of  albumenoids,  fats,  and  carbo- 
hydrates; there  must  be.  light  stimulating  drinks,  at 
least  seven  hours  of  sleep,  and  frequent  visits  to  the 
country  with  complete  freedom  from  all  duties.  Per- 
sons whose  means  permit  it  may  extend  this  anti- 
tuberculous  manner  of  living  by  trips  to  the  mountains 


—  72  — 

or  on  the  ocean  where  the  air  is  absolutely  pure  and 
free  from  dust  and  bacilli,  or  by  taking  such  forms  of 
exercise  as  will  necessitate  deep  inspiration  in  a  pure 
atmosphere,  such  as  mountain  climbing,  rowing,  trap- 
eze practice,  etc.  The  essential  thing  is  the  deep  inspir- 
ation of  pure  air  conjoined  with  outdoor  muscular  exer- 
cise. The  Pommeranian  laborers  and  drivers  have 
only  plain  food,  hard  work  and  little  sleep  all  through 
the  summer;  but  they  do  not  become  consumptive. 
On  the  contrary,  they  thrive  remarkably  well  in  the 
fresh  air,  for  they  always  enjoy  enviable  appetites, 
tireless  strength,  sound  sleep  and  the  best  of  spirits. 
Consequently,  to  prevent  phthisis,  it  is  necessary  t» 
avoid  close  and  impure  air  and  to  take  sufficient  out- 
door exercise,  moving  around  or  working. 

The  question  presents  itself,  why  are  not  prison- 
ers put  at  outdoor  work  ?  Why  are  they  packed 
together  in  close  working  rooms  and  impure  atmos- 
pheres? It  has  been  found  practicable  to  keep  the 
insane  at  rural  employments  and  to  watch  over  them; 
why  should  it  not  be  possible  in  the  case  of  prisoners? 
Why  not  allow  prisoners  to  indulge  in  athletic  and 
other  physical  exercise  ?  Surely  it  is  not  the  intention 
of  the  law  that  the  criminal,  whose  removal  from  so- 
ciety is  necessary  for  its  safety,  shall  become  sick  and 
die!  The  penal  code  aims  to  punish  and  improve, 
not  to  make  sick  and  slay.  Yet,  as  things  now  are 
and  always  have  been,  a  sentence  of  five,  ten  or  twenty 
years*  confinement,  or  for  life,  means  a  sentence  to  a 


—  73  — 
very  great  risk  of  consumption.  Certainly  the  hygiene 
of  prisons  has  been  immeasurably  improved,  and  in 
consequence  those  terrible  epidemics  of  typhus,  scor- 
butus, dysentery,  etc.,  which  once  decimated  them 
have  disappeared.  Tuberculosis  alone  remains  and 
its  mortality  statistics  are  enormous — three  or  four 
times  more  than  among  the  general  population. 

During  the  years  from  1825  to  1842,  twelve  out 
of  every  thousand  prisoners  in  the  great  English  peni- 
tentiary at  Millbank  died  of  phthisis,  while  during  the 
same  years  the  mortality  in  the  city  from  that  cause 
was  only  4.37  per  thousand.  Two  hundred  and  five 
deaths  occurred  in  the  penitentiary  during  those  years 
and  eighty  of  them  were  due  to  phthisis.  Besides 
that,  ninety  persons  were  liberated  on  account  of  ad- 
vanced tuberculosis.  In  the  Prussian  prisons,  the  pro- 
portion is  about  the  same.  At  Plotzensee,*  from 
1873  to  1882,  one  hundred  and  thirty-nine  prisoners 
died  of  whom  ninety-one  or  65.4  per  cent,  died  from 
phthisis,  and  besides,  forty  consumptives  were  liber- 
ated. Almost  all  prisons  give  a  like  proportion.!  Such 
a  mortality  from  consumption,  in  spite  of  relatively 
good  hygienic  arrangements  and  a  relatively  small 
total  mortality,  is  something  awful.  Yet  these  figures 
are  not  high  enough,  for  post  mortem  examinations  of 
convicts  who  had  died  from  other  diseases  showed  in 


*  Pl5tzensee  is  a  penitentiary  near  Berlin. — Tr. 
f  See  Appendix  for  statistics  of  American   penitentiaries. 
— Tr. 


—  74  — 
most  cases   a   more   or   less   developed  tuberculosis. 
Baer  states  as  the  result  of  his  experience  as  prison 
physician  that  it  is  an  exception  to  find  in  the  post  mortem 
of  prisoners  the  lutigs  free  from  tuberculosis. 

In  estimating  the  danger  of  consumption  in 
prisons,  there  is  another  thing  to  be  noted.  The 
highest  mortality  from  tuberculosis  is  not  found  in 
collective  prisons  and  houses  of  correction,  where  the 
deteriorated  atmosphere  of  working  rooms  and  dormi- 
tories is  breathed  by  the  prisoners  in  common,  but 
in  prisons  conducted  on  the  cellular  system.  And 
this  is  so  notwithstanding  that  under  the  latter  system 
the  healthy  prisoners  are  entirely  separated  from  the 
diseased  ones,  that  the  volume  of  air  furnish'ed  the 
prisoners  is  much  larger  than  in  the  collective  system, 
and  that  the  atmosphere  is  better  and  the  floors  and 
walls  much  cleaner.  Hence,  the  ubiquitous  nature 
of  the  tubercle  bacilli  being  understood,  the  infection 
depends  essentially  on  the  deprivation  of  outside  air 
and  outdoor  work.  That  the  diet  is  monotonous  and 
often  innutritious  cannot  be  denied;  and  psychical 
causes  also,  such  as  ennui,  lonesomeness,  repentance, 
longing  after  freedom,  etc.,  must  not  be  undervalued. 
I  believe  that  with  a  plentiful  supply  of  air  and  suit- 
able outdoor  work  in  moderation  not  only  the 
appetite  and  sleep  would  be  better,  but  the  disturbed 
and  depressed  spirits  would  be  notably  improved. 
These  considerations  deserve  the  attention  of  law- 
makers.    The  causes  of  the  disease  are  clear,  and  the 


—  75  — 
evil  cannot  begotten  rid  of  without  changing  the  man- 
ner of  working  and  increasing  the  supply  of  fresh  air. 
After  the  immense  advances  made  in  prison  hygiene 
during  the  last  fifty  years,  no  one  will  deny  the  possibil- 
ity of  changing  the  existing  rules  in  the  direction 
indicated. 

What  has  been  said  of  the  prison  applies,  mutatis 
mutandis,  to  all  trades  and  avocations  which  bring  to- 
gether a  number  of  persons  in  crowded,  unhealthy 
rooms  and  deprive  them  of  fresh  air  and  freedom. 
Statistics  of  the  French  and  English  armies  show  that 
the  ratio  of  mortality  from  consumption  quickly  de- 
creases at  the  beginning  of  wars  or  military  man- 
oeuvres, and  at  once  increases  on  return  of  the  soldiers 
to  the  barrack  life  of  peace.  The  German  army  owes 
its  small  mortality  from  this  cause,  not  only  to  the 
careful  selection  of  recruits  and  the  excellent  sanitary 
condition  of  the  barracks,  but  especially  to  the  regular 
summer  and  winter  marches  and  other  outdoor  physi- 
cal exercises. 

The  case  of  cloister-like  seminaries,  orphanages 
and  educational  institutions  is  similar.  The  more  the 
free  exercise  of  youth  is  limited  in  such  institutions, 
-the  more  frequent  is  tuberculosis,  as  Fourcault  has 
shown  by  a  number  of  most  convincing  examples.  A 
state  supervision  of  hygiene  in  seminaries  and  similar 
institutions,  especially  in  girls'  boarding  schools,  seems 
to  be  urgently  necessary.  The  youth  of  Germany 
enjoy  too  little  freedom  and   outdoor  exercise.      At 


-  76  - 

school,  especially  in  the  intermediate  schools,  an  ex- 
cessive and  pedantic  care  for  order  and  discipline 
limits  the  enjoyment  of  fresh  air  in  the  intervals  be- 
tween the  classes.  At  home,  when  supper  is  over,  the 
pupils  must  at  once  set  about  preparing  their  lessons 
for  the  morrow.  There  are,  of  course,  gifted  pupils 
who  can  prepare  their  lessons  in  an  hour  and  then 
have  time  for  play,  walking,  music,  etc.;  but  the  aver- 
age pupil  if  industrious  must  devote  the  most  of  his 
free  time  after  dinner  or  supper  to  study,  so  that  he 
seldom  or  not  at  all  gets  out  of  doors.  How  many 
children  perish  every  year  on  account  of  this  un- 
natural way  of  living  !  Contemplate  the  pale,  thin 
boys  and  girls  as,  tired  and  exhausted,  they  leave  the 
school  at  the  close  of  their  studies.  Compare  them, 
relaxed  and  over-worked,  with  English  boys  and  girls 
whose  every  minute  of  free  time,  in  or  out  of  school, 
is  given  up  to  ball  playing,  climbing,  wrestling,  rowing, 
etc.  What  a  difference  in  the  color  of  the  skin,  the 
bright  glances,  the  active  movements  !  I  know  of 
prominent  intermediate  schools  where  the  forenoon 
recess  consists  of  only  seven  or  eight  minutes  out  of 
doors,  and  even  then  the  pupils  are  not  allowed  to 
romp  or  play,  but  must  walk  about  sedately  and  con- 
verse. 

Dr.  Hermann  Weber,  of  London,  one  of  the  most 
prominent  and  most  esteemed  German  physicians  in 
foreign  countries,  and  one  well  acquainted  with  Eng- 
lish manners,  pointed  out  the  difference  in  physical 


—  77  — 
training  among  pupils  in  Germany  and  England  in  a 
paper  read  before  the  Third  Congress  of  General 
Medicine  at  Berlin.  In  a  series  of  essays,  lately  pub- 
lished, on  the  Hygiene  and  Climatic  Treatment  of 
Phthisis,  he  has  again  urgently  insisted  on  the  neces- 
sity of  careful  attention  to  the  physical  training  and 
outdoor  exercises  of  growing  youth.  Medical  atten- 
tion in  Germany  has  hitherto  been  taken  up  with  the 
hygiene  of  schools  in  relation  to  myopia.  It  is  indeed 
time  that  it  should  be  directed  to  a  sufficiency  of 
recreation,  the  choice  and  supervision  of  games,  the 
estimation  of  each  pupil's  vital  capacity,  a  systematic 
noting  of  his  weight  in  relation  to  size,  and  finally  to 
his  muscular  power.  Such  regular  investigations 
(which  ought  to  be  made  every  three  months)  would 
furnish  valuable  information  for  the  training  of  youth. 
The  school  would  become  a  channel  of  instruction  for 
parents  regarding  the  improvement  of  their  children's 
constitutions.  A  half  day  every  quarter  devoted  to 
such  purposes  would  make  no  great  inroad  in  the 
school  work  but  would  be  invaluable  in  its  results  for 
the  physical  development  of  the  pupils,  especially  of 
any  with  weak  constitutions  or  with  a  direct  disposi- 
tion to  tuberculosis.  The  physical  development  of 
children  belonging  to  these  two  classes  should  receive 
the  unremitting  attention  of  the  family  physician. 
Every  catarrh,  every  swollen  gland,  every  skin  affection, 
every  trouble,  though  apparently  unimportant  and 
hardly  worthy  of  notice  in  a  child  free  from  an  heredit- 


-  78  - 
ary  disposition,  must  receive  careful  attention  and 
treatment.  Even  if  no  such  disturbances  occur,  the 
physical  training  of  children  exposed  by  inheritance  or 
otherwise  to  tuberculosis  must  be  constantly  super- 
vised. We  should  insist  on  the  boy  or  girl  spending 
at  least  several  hours  every  day  out  of  doors.  We 
should  mark  out  the  regular  exercises  which  should 
include  ball  playing,  turning,  skating,  rowing,  bicycling, 
hill-climbing,  etc.  All  this  applies  not  merely  to 
vacations,  when  of  course  it  is  understood,  but  to 
the  school  term  when  every  day  is  spent  in  the  impure 
air  of  the  school  or  bent  over  books  at  home  or  in 
class. 

The  selection  of  an  employment  suited  to  persons 
disposed  to  tuberculosis  ought  to  be  left  to  the  physi- 
cian. Unfortunately  his  opinion  is  not  often  asked  or 
followed.  In  general,  one  may  say  that  such  persons 
should  avoid  employments  which  do  not  allow  mus- 
cular activity  and  which  require  them  to  stay  in  close 
rooms.  Pursuits  which  keep  them  continually  in  the 
open  air  and  allow  abundant  activity  to  the  muscular 
and  respiratory  systems  should  be  chosen.  The  fol- 
lowing may  be  named  as  being  least  dangerous:  Mili- 
tary service,  farming,  gardening  and  sea-faring.  Of 
the  learned  professions,  theology  and  medicine  are 
recommended,  the  former  because  of  the  country  pas- 
torates which  it  offers,  and  the  latter  because  the 
whole  world  is  open  to  the  doctor.  In  the  case  of 
girls,    sewing  and    embroidery  should  be  forbidden, 


—   79  — 
and  bodily  exercise,  walking,  mountain-climbing,  etc., 
recommended. 

These  are  not  theoretical  deductions,  but  they  are 
the  lessons  of  experience.  I  might  cite  cases  from 
my  own  experience  which  would  show  the  eminent 
importance  of  a  right  choice  of  employment  for  per- 
sons predisposed  to  disease,  but  I  know  of  no  case 
so  striking  as  one  mentioned  by  Weber,  and  which  I 
reproduce  here,  presuming  on  his  friendly  permission. 
•A  teacher  of  languages  and  his  wife,  both  sprung 
from  tuberculous  families,  died  of  phthisis  under 
Weber's  treatment,  one  shortly  after  the  other.  Of 
their  seven  children,  one  had  died  previously  of  tuber- 
cular ineningitis  basilaris.  The  other  six,  ranging  in 
age  from  one  to  twelve  years,  were  healthy  except  the 
youngest  boy,  who  was  somewhat  rachitic.  Still,  the 
inherited  constitutional  vice  of  these  poor  orphans 
was  as  bad  as  could  be  imagined.  After  the  death  of 
the  parents,  all  the  children  were  taken  by  well-to-do 
relatives  who  resided  in  a  hilly  district  of  Silesia,  and 
there  they  received  a  rational  physical  training  such 
as  I  have  indicated  above.  What  was  the  conse- 
quence ? 

The  eldest  son  remained  healthy  as  long  as  he 
devoted  hirhself  to  an  open  air  life.  But  in  his  twenty- 
third  year  he  plunged  into  the  study  of  philology. 
He  worked  at  it  day  and  night,  wholly  gave  up  taking 
physical  exercise,  and  spent  most  of  his  mealtimes  in 
his  study.  In  eighteen  months  he  died  of  "galloping" 


—  8o  — 

consumption.  The  second  son  became  a  farmer  and 
enjoyed  the  best  of  health  until  his  twenty-ninth  year. 
He  then  found  that  his  business  was  not  profitable 
enough,  and  began  to  work  in  a  mercantile  house^ 
where  he  was  shut  up  most  of  the  day  in  a  poorly 
ventilated  office.  Besides,  he  studied  industriously 
at  home.  After  two  years  of  this  intense  "  city  work,"^ 
he  began  to  suffer  from  repeated  hemoptyses  and  died 
after  hardly  two  years'  duration  of  the  disease.  The 
third  son  became  a  cavalry  man,  leads  an  active  rational 
life,  and  is  a  strong  and  fine-looking  man.  The 
fourth  child,  at  that  time  a  girl  of  five  years,  is  now 
the  wife  of  a  country  clergyman  in  a  healthy  part  of 
Silesia.  She  has  no  children  and  is  perfectly  healthy. 
The  next  son,  who  was  rachitic  in  childhood,  has  be- 
come a  strong  man.  He  is  a  farmer  in  Manitoba,. 
America,  and  the  sixth  child  (the  youngest  girl),  who- 
lives  with  him,  is  also  strong  and  healthy. 

This  very  instructive  history  shows  how  beneficial 
open  air  life  is  even  in  the  presence  of  a  pronounced 
family  tendency  to  consumption,  and  how  sternly  in 
the  same  condition,  the  violation  of  hygienic  laws  is- 
avenged.  The  history  covers  a  period  of  thirty  years^ 
but  we  cannot  say  that  it  has  reached  its  end.  Un- 
favorable circumstances,  care,  troubles,  especially  a 
sudden  change  from  an  open  air  life  to  an  indoor  one,, 
may  cause  the  latent  tuberculosis  to  develop  or  the  ex- 
isting disposition  to  yield  to  direct  infection.  Such 
cases  occur  often  enough  in  practice.     Persons  die  of 


—  8i   — 

quick  consumption  in  their  fiftieth  or  sixtieth  year,  al- 
though they  have  previously  been  always  healthy  or 
at  most  had  suffered  from  "  catarrh  "  in  their  youth  or 
later  years.  The  post  mortem  shows  in  the  lungs  of 
such  patients  old  remains  of  a  healed  tuberculosis  in 
the  form  of  crooked  scars  at  the  apices  which  enclose 
cheesy  or  calcareous  lumps  or  small  cavities  or  are  en- 
tirely indurated.  That  these  scars  are  really  remains 
of  a  healed  tuberculosis  is  undeniable,  for  industrious 
investigation  has  discovered  isolated  tubercle  bacilli 
in  them  or  in  the  old,  pigmented,  cheesy-hard  bronchial 
glands.  Such  cases  account  for  tuberculous  diseases 
in  children  which  seemed  inexplicable  because  the 
parents  were  always  supposed  to  be  perfectly  healthy: 
The  early  tuberculosis  of  the  latter  was  either  entirely 
overlooked  or  else  was  euphemistically  described  to 
the  patient  and  his  family  as  chronic  catarrh,  slight 
bronchitis,  etc.  If  one  has  an  opportunity  to  care- 
fully examine  these  cases  he  may  be  able,  even  after 
the  lapse  of  years,  to  diagnose  the  healed  phthisis 
with  tolerable  certainty,  on  account  of  the  flattened 
apices  and  the  slight  difference  in  the  intensity  of  the 
percussion  note  and  in  the  quality  of  the  respiratory 
sound.  That  is  a  very  important  point  for  a  doc- 
tor engaged  in  life    insurance  examinations. 

We  now  approach  a  part  of  the  prophylactic 
treatment,  the  importance  of  which  is  perhaps  greater 
or  mayhap  less  than  would  be  on  the  moment  im- 
agined.    I  mean  the  avoidance  of  tuberculous  contagion. 


It  necessarily  follows  from  Koch's  doctrine  that 
tuberculosis  is  contagious,  and  the  preventive  treat- 
ment must  be  regulated  from  the  same  standpoint. 
Clinical  experience,  however,  has  not  verified  an 
actual  contagion  from  man  to  man,  and  the  re- 
sults of  the  general  congresses  organized  in  France, 
England  and  Germany  have  not  favored,  so  far  as 
can  be  seen,  the  view  of  a  direct  contagion. 

Notwithstanding  that,  it  is  advisable,  when  one 
parent  is  phthisical,  to  deal  with  the  matter  plainly 
and  to  insist  that  the  patient  shall  not  kiss  spouse  or 
children,  that  the  sputa  shall  not  be  cast  on  the  carpets 
but  shall  be  suitably  disposed  of  and  disinfected,  that 
the  soiled  handkerchiefs  shall  be  separately  disinfected, 
and  that  the  room  with  all  its  carpets,  curtains  and 
furniture  shall  be  frequently  cleaned  and  always  kept 
ventilated.  If  at  all  possible  the  sick  person  should 
occupy  a  separate  room  or  certainly  at  least  a  separate 
bed.  Such  precautions,  I  admit,  are  onerous,  distaste- 
ful, and  in  a  manner  penal.  They  create  in  the 
healthy  members  of  the  family  an  aversion  to  the  pa- 
tient, a  dread  of  being  infected,  and  are  so  opposed  to 
familiar  feelings  and  customs  that  they  cannot  be  suc- 
cessfully enforced  in  practice.  Still,  if  the  father  and 
mother  are  at  all  reasonable,  these  stringent  precau- 
tions will  benefit  the  children.  Children  seem  to  become 
infected,  especially  in  the  first  years  of  life,  by  fre- 
quent kisses  of  a  consumptive  mother,  or  by  the  con- 
tamination of   their  food  with  her  saliva,  or  by  the  air 


—  83  — 

of  her  sleeping  room.  The  physician  must  appeal 
to  her  maternal  devotion  and,  by  placing  clearly  be- 
fore her  eyes  the  danger  to  her  child,  make  her  realize 
that  she  holds  its  life  and  health  in  her  hands.  The 
maternal  heart  will  unconsciously  concentrate  all  its 
tenderness  on  the  babe's  well-being.  Of  course  a 
tuberculous  mother  should  not  nurse  her  babe,  and 
great  care  should  be  taken  to  avoid  tuberculosis  in 
the  selection  of  a  wet-nurse  for  it.  So  far,  bacilli  have 
not  been  found  in  the  milk  of  consumptive  women,  but 
it  is  only  a  question  of  time  until  they  will  be  demon- 
strated, for  the  infectiousness  of  milk  from  tuberculous 
cows,  even  where  the  udders  are  not  tuberculous,  has 
been  fully  established  by  experiment. 

The  danger  of  infection  by  milk  of  tuberculous 
cows  (especially  if  the  udders  should  be  ulcerated)  is 
not  absolutely  very  great,  for  it  is  calculated  that  at 
most  only*  two  per  cent,  of  cattle  are  tuberculous. 
However,  when  we  reflect  that  the  consumer  has  usu- 
ally no  control  over  the  source  of  the  milk,  that  he 
seldom  knows  the  condition  of  the  herd  that  supplies 
it,  or  whether  it  is  the  product  of  one  sick  cow  or  a 
part  of  the  mixed  milk  of  the  entire  herd,  the  danger 
is  still  considerable.  Hence,  before  using,  all  milk 
should  be  sterilized  by  boiling.  Five  minutes'  boiling 
will  be  sufficient,  and  the  mistress  of  the  house  should 
herself  attend  to  it.  As  to  infection  from  using  the 
meat  of  diseased  cattle,  the  strict  supervision  of  the 
slaughter-houses   guards    against   that.      Butter   and 


-  84  - 

cheese  made  from  the  milk  of  tuberculous  cows  may 
also  be  infectious,  but  the  danger  from  their  use  by  a 
growing  child  with  good  digestion  is  much  less  than 
the  danger  to  a  babe  from  use  of  the  milk.  Besides, 
they  are  articles  that  may  easily  be  dispensed  with,  if 
any  anxiety  is  felt. 

The  precautions  against  infection  to  be  adopted 
by  healthy  persons  (Sisters,  nurses,  etc.)  in  charge  of 
the  sick  will  be  apparent  from  all  that  has  been  said. 
Plenty  of  fresh  air  and  outdoor  exercise  should  inter- 
vene between  the  periods  of  nursing.  Ample  sleep  is 
required.  Delay  in  the  sick-room  should  be  as  brief 
as  possible,  and  there  should  be  an  adjoining  room, 
well  ventilated  and  with  open  windows,  for  the  use  of 
the  attendants.  The  linen,  and  especially  the  hand- 
kerchiefs of  the  sick,  should  be  placed  after  use  in  a 
five-per-cent.  solution  of  carbolic  acid,  and  afterwards 
washed  separately  from  other  soiled  clothes.  The 
floors  of  the  sick-room  should  be  often  wiped  with 
moist  corrosive  sublimate  wool;  the  furniture  and 
cushions  should  be  taken  out  of  doors  once  a  week 
and  be  beaten  and  brushed;  and  the  doors,  walls,  and 
carpets  should  be  rubbed  with  bread.  The  dishes 
and  vessels  used  by  the  patient  in  eating  or  drinking 
should  also  be  kept  separate.  These  precautions  will 
enable  nurses  and  relatives  in  attendance  on  tubercu- 
lous patients  to  avoid  personal  risk  of  contagion  with- 
out in  any  way  detracting  from  the  carefulness  of  their 
attendance.     The  chief  thing  is  to  have  regular  and 


-  85  - 

sufficient  fresh  air  and  active  outdoor  exercise.  Pa- 
tients are  selfish  and  apt  to  resent  the  absence  of  the 
attendant,  so  that  the  physician  may  have  to  exercise 
his  authority  in  the  matter.  The  maintenance  of  the 
nurse's  health  and  ability  to  work  is  for  the  ultimate 
advantage  of  the  patient.  The  doctor  should  deter- 
mine how  many  hours  each  day  the  wife  or  daughter 
of  the  patient  should  take  air,  for  they  will  usually  be 
averse  to  do  of  their  own  accord  anything  that  might 
savor  of  neglect  or  indifference.  It  is  his  duty  to 
think  not  only  of  the  patient  but  also  of  the  attend- 
ants whose  unceasing  work  often  injures  themselves 
without  being  of  any  real  benefit  to  the  patient.  In- 
deed, the  care  for  the  healthy  should  often  take 
precedence  of  that  for  the  sick. 

Over  the  male  and  female  religious  orders  who 
take  care  of  the  sick,  and  their  work,  we,  as  doctors,  un- 
fortunately have  no  influence.  They  are  entirely  regu- 
lated by  the  rules  of  the  order  and  the  commands  of  the 
superior,  and  they  are  often  worked  beyond  their 
strength  by  the  demands  made  on  them  by  suffering 
humanity.  Many  a  blooming  life  would  be  preserved, 
many  an  individual  maintained  in  health  and  well-doing, 
and  certainly  sickness  and  death  would  be  diminished 
by  one  half,  if  medical  warnings  were  heeded  and  if 
considerations  of  health  were  more  regarded  than  the 
rules  of  the  order.  Hundreds  of  these  admirable  and 
devoted  beings  perish  every  year,  without  benefit  to 
humanity,    crushed    under  the    wheels   of   an  inflexi- 


—  86  — 

ble  machinery.  Say  that  the  supply  of  nurses  is  not 
adequate  to  the  constantly  increasing  demands  and 
that  this  leads  to  overwork.  I  reply  that  each  indi- 
vidual's capacity  for  work  has  its  limits,  and  that  these 
limits  are  usually  exceeded  by  the  superior  from  the 
worthy  motive  of  extending  to  as  many  suffering  peo- 
ple as  possible  the  benefits  of  a  well  regulated  system 
of  nursing.  The  remedy  should  be  placed  entirely  in 
the  hands  of  the  physician.  It  consists  in  care  for 
the  maintenance  of  health  in  the  nurses,  and  that  will 
result  in  the  greater  benefit  of  the  patients.  No  one 
will  consider  that  the  merit  of  those  noble  men  and 
women  who  voluntarily  resign  the  pleasures  of  earth 
to  devote  themselves  to  their  suffering  fellow-beings  is 
in  the  least  diminished  by  attention  to  their  own 
health  and  strength.  On  the  contrary,  every  intel- 
ligent man  will  praise  a  religious  order  which  seeks 
and  obeys  competent  advice  for  the  maintenance  of 
the  health  of  its  members  and  so  preserves  their  lives 
and  usefulness. 

I  now  proceed  to  some  other  points  of  prophy- 
laxis, which  I  judge  especially  important  for  the  pro- 
tection of  persons  who  are  disposed  or  at  least  exposed 
to  tuberculosis.  I  have  already  said  that  the  chief 
thing  necessary  is  an  abundant  inspiration  (deepened 
by  outdoor  muscular  action)  of  an  atmosphere  as  free 
as  possible  from  dust  and  bacilli.  This  is  best  attained 
by  a  sojourn  in  the  mountains  and  by  mountain-climb- 
ing, or  on  the  ocean  or  sea  coast  with  rowing  and 


—  87   — 

Other  exercises.  Few  persons,  however,  can  afford 
such  changes  of  locahty  which  may  need  to  be  pro 
longed  for  months,  or  perhaps  even  for  years.  An 
excellent  substitute  for  persons  who  can  afford  it  is  a 
visit  to  the  country,  more  or  less  distant  from  the 
great  cities,  where  there  will  be  opportunity  for  young 
men  to  hunt,  row,  ride  bicycles,  and  practice  athletic 
exercises,  and  for  young  women  to  indulge  in  gym- 
nastics, ball,  nine-pins,  and  running  games.  Every 
minute  of  favorable  weather  should  be  passed  out  of 
doors. 

What  are  called  Vacation  Colonies  have  been  estab- 
lished by  humane  societies  and  individuals  so  that 
poor  children,  especially  such  as  are  scrofulous  or 
anaemic,  or  have  an  inherited  tendency  to  disease, 
may  enjoy  the  psychic  and  hygienic  benefits  of  a 
country  sojourn.  These  institutions  are  eminently 
practical  and  deserve  to  be  introduced  as  widely  as 
possible.  The  influence  of  such  a  visit  on  the  health 
of  weak  children  growing  up  in  poverty,  in  narrow 
damp  houses  and  with  scant  food,  is  most  excellent, 
and  many  a  sinking  constitution  is  strengthened  and 
directed  into  normal  paths.  Physicians  should  strive 
in  their  respective  circles  of  practice  to  interest  as 
many  as  possible  in  such  noble  works  of  humanity. 
Children's  Homes  or  Asylums  erected  on  the  sea-side 
attain  the  same  end  and  are  of  utmost  benefit  for 
scrofulous  and  weakly  constitutions.  But  they  can 
only  benefit  a  limited  number  of  individuals,  while  the 


Vacation  Colonies  can  reach  a  far  greater  number. 
Every  city  and  town  could  organize  them,  and  in 
course  of  time  we  might  expect  that  hundreds  of 
thousands  of  poor  little  ones  would  every  year  enjoy 
their  benefits. 

For  grown  up  youth  whose  station  of  life  is  estab- 
lished, such  as  clerks,  mechanics  and  employes  gen- 
erally, it  is  of  course  more  difficult  to  supply  the  indis- 
pensable fresh  air  and  outdoor  exercise,  because 
almost  all  their  time  is  claimed  by  their  work.  Such 
young  people  ought  to  join  athletic  societies,  bicycle 
clubs,  etc.,  which  will  furnish  both  fresh  air  and  ex- 
ercise, and  drill  and  strengthen  the  entire  respiratory 
system.  That  is,  at  any  rate,  incomparably  better  than 
to  seek  the  bar-room  at  the  close  of  work  and  to  spend 
hours  in  a  hot  and  smoky  atmosphere.  The  sputa  of 
bar-room  loungers  (which  Panizza  and  I  examined 
largely)  showed  by  the  abundance  of  cells,  coal  par- 
ticles and  myelin  that  the  respiratory  organs  are  sub- 
jected in  such  places  to  a  continuous  even  if  slight 
irritation.  Such  a  condition,  joined  to  incomplete  ex- 
pansion of  the  lungs,  favors  the  disposition  to  take  up 
bacilli.  On  the  contrary,  gymnastic  exercises  (even 
in  doors,  provided  the  dust  is  kept  down  with  tan- 
bark)  are  a  great  benefit  not  only  for  the  lungs  and 
muscles  of  respiration  but  for  all  the  functions  of  the 
body. 

I  cannot  conclude  this  chapter  on  prophylaxis 
without  referring    to   hydrotherapy    which    occupies  a 


very  important  position  both  for  the  prevention  and 
for  the  cure  of  tuberculosis.  Winternitz,  to  whom 
principally  we  owe  scientific  hydrotherapy,  has  pub- 
lished his  experience  relating  to  its  use  in  this  disease 
in  a  brief  essay  entitled  "  Studies  of  the  Pathology 
and  Hydrotherapy  of  Pulmonary  Phthisis,"  which  I 
strongly  recommend  to  the  reader's  special  study. 
My  experience  of  the  "  hardening "  method  where 
there  is  an  hereditary  or  acquired  disposition  agrees 
fully  with  his.  Water  at  a  suitable  temperature  is  the 
best,  simplest,  most  general,  and  most  available  agent 
for  strengthening  and  "  hardening  "  a  weak  body  or 
one  disposed  to  catarrhs  and  colds.  Even  a  simple 
rubbing  down  of  the  entire  body  with  a  large  moist 
cloth  after  getting  up  in  the  morning  accustoms  the 
skin  to  sudden  cooling  off.  At  first  the  cloth  should 
be  wrung  out  of  lukewarm  water  and  later  on  cold 
water  may  be  used.  The  practice  drills  the  vaso- 
motor nerves  of  the  peripheral  arteries  to  prompt  re- 
action. It  acts  centripetally  as  a  thermic  irritant  to 
the  central  nervous  system,  stimulating  and  refresh- 
ing it,  and  indirectly  on  the  innervation  and  function 
of  the  respiratory,  circulatory  and  digestive  systems. 
At  first,  water  of  about  24°  R.  (86°  F.),  is  to  be  used, 
and  the  cloth  should  be  well  wrung  out.  On  each 
succeeding  morning  the  temperature  of  the  water  may 
be  reduced  ^°  R.  (i^°  F.).  Winternitz  does  not  con- 
cede that  a  milder  effect  is  produced  by  the  use  of 
lukewarm    water  than    by    cold  water.       But    in  this 


—  90  — 

point  my  experience  differs  from  his,  possibly  because 
his  was  derived  from  his  water-cure  establishment 
whilst  mine  is  drawn  chiefly  from  private  practice.  It 
is  not  at  all  a  matter  of  indifference,  I  can  say  posi- 
tively, whether  one  order  a  sensitive  body  rubbed 
with  cloths  wrung  out  of  water  at  12°  R.  (59°  F.) 
or  24°  R.  (86°  F.)  temperature.  Nervous  and  weak 
persons  shrink  from  the  cold  applications  and  more 
readily  submit  to  the  warmer  ones.  It  is  very  import- 
ant that  the  friction  should  be  brief,  only  a  minute 
long,  and  that  the  cloth  should  be  well  wrung  out 
(not  "wringing  wet"  as  in  sponging  or  splashing). 
The  aim  is  to  produce  a  thermic  and  mechanical 
irritation  of  the  superficial  nerves  and  vessels, 
not  to  deprive  the  body  of  any  considerable  heat. 
This  latter  effect  would  be  produced  if  the  cloths 
were  wet  with  cold  water.  To  attain  the  desired 
end,  very  low  temperatures  are  not  needed  and  it  is 
seldom  necessary  to  go  below  15°  R.  (66°  F.). 

In  weak  constitutions  where  appetite  and  assimi- 
lation are  poor,  I  order  from  one-half  to  one  pound  of 
cohimon  salt  and  one-quarter  liter  (about  8  fl  §  )  of 
caustic  potash  to  be  added  to  the  water  after  the  third 
week,  so  as  to  make  an  artificial  salt  bath.*  This 
produces  a  more  lively  and  lasting  irritation  of  the 


*The  German  word  is  Soole.  It  means  a  saturated  solu- 
tion of  salt,  either  from  natural  salt  wells  or  made  artificially. 
— Tr. 


—  91   — 

nerves,  and,  like  mineral  baths,  improves  the  assimila- 
tion and  nutrition.  Such  friction  baths  can  be  used 
in  private  practice  everywhere  and  amongst  the  poor- 
est people.  They  entail  no  expense  and  conflict  with 
no  duties,  because  they  are  taken  immediately  after 
arising,  and  the  patient  at  once  dresses  and  can  go  about 
his  work.  Unless  the  patient  is  very  weak,  I  do  not 
permit  him  to  return  to  bed  after  the  rubbing.  It 
would  be  much  better  if  he  would  at  once  take  some 
outdoor  exercise  if  the  weather  permit,  and  return 
after  an  hour  to  his  breakfast.  Very  delicate  persons, 
especially  women,  may  be  allov/ed  a  cup  of  warm  tea 
or  coffee  before  the  friction  bath,  but  all  others  should 
be  fasting. 

Patients  who  have  no  one  to  assist  them  with  the 
rubbing  may  improve  matters  by  using  a  large  towel, 
or  they  may  substitute  a  douche  bath  for  the  friction 
bath.  This  rain  or  douche  bath  is  not  so  effective, 
because  its  stimulation  is  not  so  intense  nor  does  it 
reach  the  entire  surface.  However,  it  is  still  an  ex- 
cellent method  of  hardening  and  invigorating  the 
body. 

Local  frictions  with  cogniac  in  which  salt  has 
been  dissolved  are  practiced  in  some  sanitariums  for 
chest  diseases,  but  I  do  not  attribute  any  particular 
effect  to  them.  They  miss  the  essential  thing,  that  is, 
the  sort  of  shock  which  is  produced  by  wrapping  the 
body  in  a  wet  cloth  or  sheet,  and  which  innures  the 
surface  to  sudden  cold  or  dampness,  produces  prompt 


—  92  — 

action  of  the  superficial  vessels,  and  hardens  the  sen- 
sitive nerves  of  the  skin. 

Should  a  more  thorough  treatment  be  desirable, 
the  patient  may  be  sent  to  a  water-cure  establishment. 
This  is  necessary,  however,  only  in  persons  who  are 
deficient  in  will  power.  Most  persons  have  firmness 
enough  to  persevere  for  months  and  years  in  such 
friction  baths  in  their  homes  and  with  the  help  of  their 
relatives  or  servants.  This  simple  procedure,  which 
may  be  varied  in  various  ways,  is  one  of  the  best  with- 
in reach  of  the  physician.  It  overcomes  sensitiveness 
to  changes  of  temperature,  wind  and  dampness,  and 
renders  excessive  clothing  unnecessary.  It  overcomes 
constant  slight  perspiration,  eternal  nasal  and  bron- 
chial catarrhs,  rheumatic  disposition,  etc.,  and  gives  to 
the  body  a  freshness  and  elasticity  which  can  be  pro- 
cured in  like  degree  only  by  mineral  and  sea  baths. 
Its  great  advantage  in  being  used  at  home,  without 
expense  and  for  months  and  years  if  needed,  recom- 
mends it  especially  for  people  of  moderate  means. 

The  natural  mineral  and  sea  baths  are,  for  those 
who  can  afford  to  go  to  them,  an  excellent  agent  for 
invigorating  and  strengthening  the  constitution  and 
especially  the  sensitive  respiratory  surfaces.  Their 
effect  is  due  to  various  causes.  In  the  sea  baths,  we 
have  the  chemical  and  thermic  influences  of  the  cold 
salt  water,  the  mechanical  irritation  of  the  waves,,  the 
rapid  movement  of  the  air  which  is  both  free  from 
dust  and  bacilli  and  rich  in  water  and  salt,  and  the 


—  93  — 
outdoor  life.  All  these  agencies  affect  the  nervous 
system  and  through  it  all  the  organic  functions,  stimu- 
lating and  invigorating  all,  and  especially  the  appetite, 
assimilation  and  respiration.  The  lungs  are  impelled 
to  deep  inspiration,  and  their  epithelial  cells  are 
strengthened  by  the  quick  motion  and  other  favorable 
conditions  of  the  air.  The  influence  of  mineral  baths 
is  analogous,  especially  those  situated  in  moun- 
tain districts  and,  like  Reichenhall  and  Kreuth,* 
rich  in  special  curative  agencies.  In  addition  to 
the  direct  effects  of  such  baths,  the  constant  climbing 
of  the  hills  in  the  pure  air  improves  and  deepens 
respiration.  Systematic  exercise  in  mountain  climbing 
is  one  of  the  most  beneficial  practices  for  various 
chronic  lung  troubles,  and  its  results  are  more  effec- 
tive and  permanent  the  higher  the  level  at  which  the 
patiept  resides,  the  purer  and  thinner  the  air,  the 
lighter  the  atmospheric  pressure  and  the  less  there  is 
of  rain,  wind  or  fog. 


*  Reichenhall  and  Kreuth  are  Bavarian  Alpine  resorts. 
The  former  has  salt  baths,  "pine  needle"  baths,  and  an 
establishment  for  the  whey  treatment;  the  latter  has  sulphur 
baths. — Tr. 


CHAPTER  II. 

DIRECT     TREATMENT— HYGIENIC- CLIMATIC- 
DIETETIC— MEDICINAL. 

All  the  important  curative  agencies  mentioned  in 
the  preceding  chapter  are  valuable  not  only  for  deal- 
ing with  an  inherited  or  acquired  disposition  to  tuber- 
culosis or  scrofulosis,  but  also  for  the  treatment  of 
phthisis  after  it  has  become  manifest  and  is  proven  by 
the  presence  of  tubercle  bacilli  in  the  sputum.  It  is 
hardly  necessary  to  repeat  that  the  bacillus  and  its 
products  and  effects  in  the  lungs  must  always  occupy 
the  foremost  place  in  our  studies.  After  it  has  once 
gained  admission  into  the  organism,  the  aim  of  all  our 
treatment  must  be  to  combat  and  destroy  it.  Unfor- 
tunately there  seems  at  present  no  prospect  of  accom- 
plishing that  aim  in  a  visible  time.  Fraentzel,  dne  of 
the  most  deserving  and  indefatigable  investigators  in 
this  department  of  medicine,  candidly  admits  that  the 
result  of  all  the  experiments  thus  far  made  at  the  bed- 
side and  in  the  bacteriological  laboratories  is  to  show 
our  inability  to  destroy  bacilli  or  cocci  domiciled  in 
the  pulmonary  tissues  by  medicines  whether  admin- 
istered in  gaseous  form  or  by  atomization. 

The  best  remedies,  the  remedies  which  medical 
experience  shows  to  have  produced  the  best  results  in 
the  beginning  of  pulmonary  tuberculosis,  are  still  the 
physical  ones — air,  climate,  exercise  and  water.  Diet 
occupies  only  a  secondary  place. 


—  95  — 

Considering  the  importance  of  a  definite  and  per- 
severing treatment,  all  thought  and  effort  should  be 
directed  to  the  selection  of  a  proper  course  in  the  be- 
ginning of  the  disease,  when  hope  of  cure  is  still  justi- 
fiable. Hereditary  disposition,  physical  constitution 
of  the  patient  and  his  entire  family,  age,  sex,  tempera- 
ment, mental  endowments  and  condition,  tractable- 
ness  and  firmness,  social  rank  and  employment, 
financial  circumstances — all  these  factors  vary  in  dif- 
ferent cases,  and  all  affect  the  selection.  But  mani- 
fold as  may  be  the  differences  in  individual  cases,  the 
curative  agencies  already  mentioned  are  of  funda- 
mental importance  for  all  and  should  never  be 
omitted. 

The  fresh  air  treatment  occupies  the  first  place. 
To  a  certain  extent,  it  can  be  employed  in  all  condi- 
tions of  life,  though  of  course  modified  according  to 
circumstances,  and  consequently  more  or  less  limited 
in  its  effects.  The  simplest  way  is  to  keep  a  window 
open  day  and  night,  or  to  remain  constantly  out  of 
doors,  sitting  or  lying  as  preferred,  and  protected  in 
bad  weather  by  some  simple  shelter.  In  addition  to 
this,  the  patient  should  practice  deep  inspiration, which 
may  be  done  by  climbing  any  hill  or  mountain  near 
his  house,  or  by  regular  gymnastic  exercises,  such  as 
the  use  of  bars,  swinging  ropes,  etc.  It  is  true  that 
pulmonary  hemorrhage  may  occur  in  such  exercises, 
but  I  can  scarcely  believe  that  it  is  more  frequent  in 
consequence  of  a  stronger  expansion  of  the  lungs  than 


-  96  - 

otherwise.  Mountain  health  resorts,  which  are  acces- 
sible to  persons  of  means,  are  also  a  form  of  the  fresh 
air  treatment.  Such  resorts  for  persons  with  pulmon- 
ary troubles  are  numerous  and  excellent.  They  are 
found  in  all  high-lying  districts  from  the  Lower  Alps 
to  the  elevated  vallies  of  the  Grissons,  and  all  produce 
good  results.  Their  success  seems  to  depend  not  so 
much,  if  at  all,  on  elevation  of  site  as  on  the  purity  of 
air  and  the  exercise  of  the  lungs. 

When  I  designate  deep  inspiration  of  pure  moun- 
tain or  sea  air,  accompanied  by  vigorous  action  of  the 
respiratory  and  other  muscles  as  the  most  essential 
part  of  treatment,  I  mean  that  bacilli  and  cocci  do  not 
thrive  well  in  a  constant  current  of  pure  air  through- 
out the  lungs,  and  that  further  settlements  of  them 
are' prevented  by  the  energetic  action  of  the  lungs  and 
by  the  renewal  of  the  air.  High  temperature  and 
stationary  condition  of  the  air  favor  the  bacilli,  and 
hence  good  ventilation  and  low  temperature  must  be 
beneficial  to  the  patient.  I  will  not  decide  whether 
other  causes  may  not  also  contribute  to  the  effect,  as 
for  example  the  improvement  in  the  pulmonary  circu- 
lation produced  by  the  deep  inspiration,  and  the  freer 
expectoration  of  infectious  matter  resulting  from  the 
increased  action  of  the  lungs.  Hence  warm  climates 
are,  in  my  opinion,  less  beneficial  than  cool  ones,  pro- 
vided, however,  that  other  atmospheric  conditions,, 
such  as  stillness  of  the  wind,  sunshine,  etc.,  are  favor- 
able, and  that  the  patient  can  be  constantly  in  the  open 


—  97  — 
air.  This  opinion  is  confirmed  by  the  excellent  re- 
sults obtained  at  Gorbersdorf,  Davos*  and  the  elevated 
vallies  of  the  Grissons,  the  Andes  and  the  Cordilleras, 
where  the  patients  can  be  much  out  of  doors  even  in 
the  winter.  It  is  further  confirmed  by  the  immediate 
and  rapid  benefits  derived  from  polar  journeys  and  by 
the  fact  that  tuberculosis  is  scarcely  to  be  found 
among  the  peoples  of  Iceland,  the  Hebrides,  the 
Faroe  islands,  the  Shetland  islands,  and  the  northern 
districts  of  Norway. 

The  question  as  to  the  respective  merits  of  public 
spas  and  private  sanitariums  is  one  of  methods,  not  of 
principles.  It  is  certain  that  the  strict  discipline  of  a 
sanitarium  has  the  advantage  of  avoiding  many  dangers 
(such  as  pleasure  parties,  colds,  indigestion,  etc.),  to 
which  the  guest  at  a  watering  place  is  exposed  through 
ignorance,  thoughtlessness  or  lack  of  self-control. 
There  is  besides  a  better  guarantee  for  regularity  of 
exercise  and  better  precautions  against  taking  cold. 
On  the  other  hand,  sensitive  people  find  something 
abhorrent  about  sanitariums  and  feel  much  better  in 
public  watering  places.     If  patients  will  patiently  and 


*  Gorbersdorf .  is  situated  in  Prussian  Silesia,  1,840  feet 
above  the  sea.  Dr.  Hermann  Brehmer  (who  is  still  living) 
established  there  a  celebrated  sanitarium  for , consumptives. 
It  was  the  first  erected  at  an  elevation  exempt  from  bacilli. 
Davos  is  in  the  canton  of  the  Grissons  in  Switzerland,  5,940 
feet  above  the  sea.  It  is  a  favorite  summer  and  winter  resort 
for  persons  with  pulmonary  and  nervous  trouble. — Tr. 


perseveringly  follow  the  directions  of  their  physician, 
they  will  obtain  satisfactory  results  in  the  latter  resorts. 
Of  this  I  have  had  plenty  of  evidence  among  my  pa- 
tients at  Reichenhall,  Meran,*  and  other  mountain 
resorts. 

In  the  selection  of  a  health  resort,  some  authors 
attach  great  importance  to  the  moisture  of  the*  atmos- 
phere. But  as  far  as  actual  experience  goes,  we 
must  say  that  a  dry  climate  with  little  rain  and  fog  is 
generally  more  suitable  for  tuberculous  persons  than  a 
moist  one.  As  regards  winds,  provided  the  purity  of 
the  air  is  the  same,  the  still  atmosphere  of  high-lying, 
sunlit  vallies  is  to  be  preferred,  because  there  is  far  less 
danger  of  taking  cold  when  out  of  doors  or  climbing 
the  hillsides.  The  condition  of  the  atmosphere  as  re- 
gards its  supply  of  ozone,  or  its  poverty  in  oxygen  or 
(as  in  the  upper  Alps)  its  slight  pressure,  does  not 
affect  the  therapeutic  value  of  health  resorts.  The 
celebrated  pine  woods  of  many  places,  as  for  example 
in  the  Black  Forest,  to  the  aromatic  exhalations  of 
which  a  sterilizing  influence  on  the  diseased  lung  sur- 
faces is  ascribed,  possess  also  the  inestimable  advant- 
age of  a  dry,  warm  and  wind  protected  situation,  ex- 
cellent for  the  prolonged  enjoyment  of  the  open  air. 


*Meran  is  a  winter  resort  situated  in  Southern  Tyrol, 
about  HOC  feet  high.  Fully  10,000  visitors  go  there  each 
season  (from  September  to  June).  The  grape,  whey  and  milk 
treatment  are  practiced  and  there  are  also  pneumatic  chambers. 
— Tr. 


—  99  — 

It  is  impossible  to  give  in  this  short  treatise  all 
the  details  of  climatic  treatment.  It  would  be  well  if 
physicians  could  personally  visit  and  investigate  the 
most  important  watering  places  and  climatic  resorts. 

Finally,  I  take  up  that  part  of  the  treatment 
which  enters  the  daily  practice  of  the  physician  and 
which  is  consequently  of  great  importance,  no  less  to 
him  than  to  his  patient.  It  includes  dietetics  and  the 
treatment  of  the  fever  which  accompanies  tuberculosis 
of  the  lungs.  The  treatment  of  other  disturbances 
and  complications  is  reserved  for  the  third  and  last 
chapter. 

The  diet  of  tuberculous  patients  should  be  regu- 
lated according  to  the  stage  of  the  disease,  the  rapid- 
ity of  its  course,  and  the  condition  of  the  constitution. 
In  the  initial  stage,  when  nutrition  is  as  yet  not  essen- 
tially impaired,  but  the  excitability  of  the  heart  and 
the  tendency  to  congestions  are  considerable,  it  is  ad- 
visable to  decrease  the  albuminoids  and  to  correspond- 
ingly increase  the  carbohydrates  and  fats.  Vegetable 
diet  has  a  slightly  laxative  effect  and  is  beneficial  in 
proportion  to  its  amount  of  vegetable  acid  alkalies,  as 
in  fresh  vegetables,  fruits,  etc.  For  this  reason  the 
grape  cure  and  the  whey  cure  conjoined  with  moun- 
tain air  are  excellent  in  the  first  stage.  Raw  and 
cooked  fruits,  cider  and  the  like  are  also  appropriate. 
Stimulating  foods  and  drinks  like  tea,  coffee  and  al- 
cohol (which  should  be  allowed  only  moderately  and 
in  the  form  of  beer)  are  unsuitable  on  account  of  the 


excessive  irritability  of  the  heart.  The  koumiss  and 
kephir*  treatment  are  good  in  the  first  stage  if  the 
patient  can  visit  the  steppe  of  Samara,  or,  at  least, 
stay  out  of  doors  entirely.  Cod-liver  oil  is  also  useful 
if  the  patient  has  good  digestion. 

In  the  later  stages,  when  the  constitution  is 
undermined  by  the  fever  and  the  appetite  has  failed, 
it  is  difficult  to  adequately  nourish  the  patient  on  ac- 
count of  the  anorexia.  If  the  fever  is  continuous,  it 
must  be  met  as  will  be  hereafter  explained.  If  it  is 
slight  and  confined  to  certain  hours,  nutriment  should 
be  given  as  far  as  possible  when  it  is  not  present, 
even  though  the  patient  should  have  to  force  himself 
to  eat.  I  am  sure  that  want  of  appetite  and  dyspepsia 
do  not  always  depend  on  the  fever,  but  that,  like  the 
night  sweats,  they  may  be  purely  a  nervous  disturb- 
ance and  consequently  accessible  to  direct  treatment. 
Too  much  reliance  should  not  be  placed  on  medicines, 
though  the  simple  and  aromatic  bitters  with  or  with- 
out  iron  are  often    helpful.     We   should    rather   lay 

*  Kephir,  or  kefir,  is  a  liquor  made  from  the  milk  of  a 
cow  or  mare  by  the  addition  of  a  special  ferment.  The  fer- 
ment is  contained  in  the  grains  of  a  plant  which  grows  in  the 
Caucasus.  There  are  three  grades  of  kefir,  according  to  the 
time,  one  two  or  three  days,  taken  in  its  preparation.  The 
first  or  young  kefir  is  used  in  pulmonary  troubles.  It  has  a 
laxative  effect.  The  third  or  strong  has  a  constipating  effect 
and  is  used  in  abdominal  disorders.  In  the  beginning  two  or 
three  glasses  are  to  be  taken  daily  and  gradually  increased  to 
six  or  seven. — Tr. 


stress  on  fresh  air,  especially  mountain  air,  outdoor 
exercise,  entire  freedom  from  business  cares,  and  a 
good,  plentiful  and  varied  diet.  In  choosing  a  health 
resort  for  consumptives,  the  kitchen  is  not  the  least 
important  thing  to  be  considered,  for,  even  with 
slight  appetite,  better  nutrition  will  be  secured  by 
abundance  and  variety  of  well-prepared  food  than  by 
a  scanty,  monotonous  and  plain  bill  of  fare. 

Instead  of  relying  upon  the  allurement  of  a  well 
laden  table,  Debove  has,  in  cases  of  anorexia,  resorted 
to  compulsory  over-feeding  either  by  the  use  of  an  oeso- 
phageal tube  or  by  overcoming  the  patient's  resist- 
ance. Our  own  experiments  have  shown  that  this 
plan  of  "  sur-alimentation  "  produces  brilliant  but  only 
temporary  results  in  many  cases.  After  several  weeks, 
the  excessive  quantity  of  food,  out  of  proportion  to 
the  gastric  and  intestinal  juices,  creates  disturbances 
of  digestion,  flatulence,  nausea,  diarrhoea,  etc.  The 
treatment  must  be  discontinued,  and  in  many  people 
its  resumption  at  once  brings  on  a  recurrence  of  the 
disturbances  especially  where  the  assimilation  is  bad 
and  the  muscular  action  is  insufficient. 

The  fattening  treatment  of  Weir  Mitchell  is  more 
sensible  and  more  permanent  in  its  results.  The 
nutriment  is,  indeed,  supplied  during  complete  rest  of 
the  body,  but  assimilation  is  aided  by  judicious  mas- 
sage in  lieu  of  voluntary  muscular  action.  This  passive 
condition  produces  in  many  cases  a  good  effect  upon 
the  general  economy,  and  not  onJy  results  in   an   in- 


crease  of  fat  but  also  tones  up  in  a  surprising  manner 
the  general  nervous  and  muscular  system.  I  would 
recommend  this  treatment  in  cases  of  beginning  or 
even  advanced  tuberculosis  where  there  is  little  or  no 
fever  and  where  the  constitution  and  appetite  do  not 
improve  on  account  of  the  excessive  nervous  irrita- 
bility. Such  neurasthenic  patients,  especially  of  the 
gentle  sex,  often  improve  wonderfully  under  the  en- 
forced rest  in  spite  of  their  tuberculosis. 

As  to  drinks,  alcohol  has  more  and  more  during 
the  last  ten  years  acquired  and  deserved  a  prominent 
place  in  the  treatment  of  tuberculosis.  I  do  not  re- 
commend strong  alcoholic  drinks  like  wine  and 
cogniac  in  the  early  stages  of  the  disease,  and  in  ex- 
citable constitutions,  irritable  heart,  tendency  to 
hemoptysis,  etc.  In  such  cases  I  allow  only  light  beer 
in  moderation  and  cider,  or  else  I  exclude  all  alcohol 
and  permit  only  milk.  The  milk  diet  often  produces 
excellent  results  when  the  stomach  is  good,  but  daily 
investigation  must  be  made  to  forestall  any  gastric 
disturbance.  In  the  later  stages  of  the  disease, 
alcohol  is  invaluable.  It  is  used  in  almost  all  sani- 
tariums and  health  resorts  and  in  relatively  large 
quantities,  one  to  one  and  a  half  liters  (about  three 
pints)  of  wine  and  fifty  to  sixty  grams  (about  two 
fiuidounccs)  of  cogniac  each  day.  It  invigorates  the 
nervous  system,  gives  a  pleasant  feeling  of  warmth 
and  strength  which  is  of  value  in  the  open  air  treat- 
ment especially  during  cool  weather,  increases  energy 


—   I03  — 

and  endurance  in  exercising,  produces  quieter  sleep 
and  diminishes  the  night  sweats.  It  produces  these 
effects  in  various  ways.  It  seems  to  me  to  act  rather 
by  stimulating  the  central  nervous  system  and  conse- 
quently the  separate  functions  than  by  its  inhibitory 
influence  on  assimilation  (its  "  labor-saving  effect  ")  or 
by  its  action  on  the  heart.  That  is  shown  by  its  effect 
on  the  psychical  and  intellectual  functions  and  by  the 
diminution  of  night  sweats  which  are  due  to  weakness 
of  the  nerve  center  of  the  sweat  glands. 

The  quality  of  wine  may  be  regulated  by  the  pa- 
tient's taste,  but  the  fiery  red  wines,  the  Valletelino, 
Burgundian  and  red  Hungarian  wines  suit  better  than 
light  white  wines.  The  kind  and  quantity  of  alcohol 
must  be  determined  according  to  the  individual  case. 
Where  the  intestinal  tract  is  very  sensitive  and  there 
is  a  tendency  to  diarrhoea,  with  or  without  the  presence 
of  intestinal  tuberculosis,  an  excellent  evening  drink  is 
mulled  wine,  that  is,  red  wine  boiled  with  some  cinna- 
mon, sugar  and  cloves.  The  high  temperature  of  the 
wine  and  the  aromatic  additions  to  it  produce  a  very 
pleasant  and  anti-diarrhoeic  effeet  on  the  intestinal 
mucous  membrane.  The  excellent  "berry  wine" 
(Beerenwein)  or  "  forest  wine  "  (Waldwein)  from  the 
factory  of  Fromm  &  Co.,  of  Frankfort,  is  well  adapted 
for  making  mulled  wine,  as  its  tannin  is  least  brought 
out  in  that  form.  The  "  berry  wine  "  is  also  highly 
recommended  when  slightly  warmed,  but  not  boiled. 
Delicate  patients  should  not  drink  cold  wines,  and  in 


—   I04  — 

fact  red  wines  do  not  taste  well  when  cold.  Cogniac 
should  be  given  (one  or  two  tablespoonfuls)  chiefly 
in  the  evening  and  in  the  form  of  cold  or  hot 
grog.  Many  patients  have  an  idiosyncrasy  in  regard 
to  it  and  cannot  drink  it.  It  gives  them  palpitation 
of  the  heart  or  causes  sleeplessness,  etc.  In  such 
cases,  arrac,  rum,  brandy  or  whiskey  should  be  tried,  or 
wine  alone  be  used. 

The  fever,  which  unfortunately  too  often  presents 
a  most  difficult  problem,  will  be  met  in  the  beginning 
of  the  disease  and  in  slight  cases  of  relapse  by  the 
open  air  treatment  and  the  dietetic  regulations.  Phy- 
sicians at  health  resorts  have  frequent  opportunity  to 
witness  the  satisfactory  antipyretic  effects  of  the  air 
treatment.  Patients  who  at  home  kept  their  rooms 
for  weeks  at  a  time  on  account  of  the  fever  are  soon 
freed  from  it  at  Reichenhall,  Bozen,*  Meran  or  San 
Remo.  They  quickly  recover  from  its  effect  and  not 
seldom  escape  it  through  an  entire  winter.  Unfortun- 
ately this  simple  and  pleasant  therapy  is  not  always 
sufficient,  at  least  not  in  advanced  cases.  Then  alco- 
hol, which  possesses  a  certain  degree  of  antipyretic 
power,  must  be  used.  The  antipyretics  also  (say  what 
one  will  against  them)  are  indispensable.  The  best  of 
these  are  atitipyruie  and  aritifebi-ine.  Though  they 
may  help   but   little    in    progressive  cases  with    high 


*Bozen  is  a  town  in  Tyrol,  noted  as  a  winter  resort.  San 
Remo  (made  famous  by  the  sickness  of  the  ill-fated  and  noble 
Emperor  Frederick)  is  situated  on  the  Riviera  of  Genoa. — Tr. 


—  I05  — 

fever,  they  are  nevertheless  indispensable  on  account 
of  the  sense  of  well-being  which  they  produce.  In 
moderate  fever,  they  are  often  very  satisfactory  especi- 
ally when  long  used,  because  patients  are  enabled  to 
go  out  more  into  the  open  air,  and  the  appetite  and  sleep 
improve.  During  the  past  few  years  I  have  preferred 
antifebrine.  I  give  it  in  capsules,  three  or  four  times 
in  the  twenty-four  hours  in  doses  of  0.3  grams  (4.6 
grs.).  When  the  fever  occurs  at  a  definite  time,  de- 
noted by  chill  or  shivering,  we  may  attempt  to  abort 
it  by  giving  at  one  dose  0.6  gram  (9.2  grs.)  two  or 
three  hours  earlier  and  following  that  during  the  after- 
noon or  night  by  two  doses  of  0.3  gram.  Some  sherry 
or  marsala  is  recommended  to  be  taken  after  the  drug. 

In  many  cases,  it  is  best  to  check  further  develop- 
ment of  the  fever  by  treating  the  slight  relapses  as  is 
done  in  intermittent  cases.  For  this  purpose  the 
patient  should  carefully  take  his  temperature  regularly 
three  or  four  times  a  day,  and  his  weight  should  be 
ascertained  every  two  or  three  days.  In  that  way  he 
will  be  able  bo  correctly  distinguish  the  fever  attacks 
from  simple  discomforts  and  dyspeptic  disturbances, 
and  so  use  the  antifebrine  at  the  right  time.  In  some 
the  fever  disappears  only  with  a  change  of  locality. 
Lukewarm  or  warm  baths  gradually  cooled,  with 
or  without  the  addition  of  salt,  and  matutinal  frictions 
with  saline  waters  are  also  beneficial. 

Creasote,  first  warmly  advocated  by  Bouchard  in 
1877,  and  after  him  used  with  success  by  Reuss,  Som- 


—   io6  — 

merbrodt  and  Fraentzel,  may  be  tried,  especially  in 
fresh  cases  with  little  or  no  fever.  It  is  said  to  de- 
crease cough,  mucous  secretion  and  fever,  to  increase 
appetite  and  weight,  and  to  dissipate  the  phenomena 
of  consolidation.  Although  many  cases  do  not  im- 
prove and  many  patients  cannot  endure  the  drug,  still, 
according  to  those  authors,  the  greater  number  are  so 
much  benefitted  that  a  long-continued  trial  (from 
three  months  to  a  year)  ought  to  be  made  in  suitable 
cases  and  especially  in  persons  whose  employment  or 
poverty  will  not  permit  recourse  to  the  systematic 
open  air  treatment.  On  account  of  its  disagreeable 
taste,  the  drug  should  be  given  in  capsules,  each  con- 
taining (according  to  Sommerbrodt's  prescription) 
0.05  gram.  (.75  gr.)  creasote  and  0.2  (3  grs.)  tolu  bal- 
sam. One  or  two  capsules  should  be  taken  after  each 
principal  meal  with  a  tablespoonful  of  water.  After 
two  months,  it  should  be  discontinued  for  a  month. 
The  entire  course  should  last  a  year  or  longer.  Bou- 
chard's original  prescription,  adopted  by  Fraentzel, 
was: 

5     Creasote,  13.5  (  3  iijss). 

Sherry  wine,  ^  litre  (fl  |  xxv). 

Rectified  spirits,  200.0  (  %  vij). 

Tincture  of  gentian,  30.0  (§j). 
M.  Sig. — A  tablespoonlul  to  be  taken  in  a  glass  of  water 
two  or  three  times  a  day. 

Menthol  has  lately  been  recommended  by  A.  and 
S.  Rosenberg  as  an  anti-parasitic  remedy.     It  may  be 


—  loy  — 

taken  internally  six  times  a  day  in  doses  of  one  to 
one  and  a  half  grams  (15.4  to  23  grs.)  or  by  inhalation 
with  Schreiber's  apparatus,  using  fifteen  or  twenty 
drops  of  a  twenty-per-cent.  oily  solution  several  times 
a  day.  Confirmation  of  its  good  results  is  still  lack- 
ing. 

Other  antiseptic  drugs  have  been  tried  in  the 
form  of  gaseous  or  atomized  inhalation,  without,  how- 
ever, having  produced  any  great  results.  Such  are 
pine  and  beech  tars,  oil  of  mountain  pine,*  turpentine, 
oil  of  eucalyptus,  etc.  Though  a  directly  curative 
effect  has  not  been  established  for  these  inhalations, 
they  are  to  be  recommended  for  impregnating  the  at- 
mosphere of  the  patient's  room,  especially  of  his  sleep- 
ing room.  They  certainly  have  a  real,  though  slight, 
antiseptic  effect,  and  they  reach  the  diseased  parts  of 
the  lungs  which  harbor  the  bacilli  and  are  exposed  to 
the  inroads  of  secondary  colonies  of  cocci. 

Arsenic  is  another  drug  recommended  for  tuber- 
culosis. It  was  long  used  in  France,  England  and 
Russia,  and  has  lately  been  recommended  on  theoreti- 
cal grounds  by  Dr.  Hans  Buchner.  In  practice,  how- 
ever, its  claims  are  not  confirmed,  at  least  not  as  a 
specific.     As  a  tonic  for  the  nervous  system,  it  seems 


*  Oleum  pini  pumilionis,  Hancke,  also  called  ol,  tem- 
p'inum,  or  krummholzcel.  It  is  distilled  from  the  young 
branches  of  the  mugho  or  mountain  pine,  from  which  "Hun- 
garian balsam "  is  obtained.  A  refined  form  of  it  has  been 
lately  introduced,  called  pumiline. — Tr. 


—  io8  — 

to  hare  produced  good  results  in  many  cases  of  torpid 
phthisis.  I  have  no  personal  experience  as  to  the 
results  of  carbonic  acid  inhalations  or  of  Bergeon's 
gas  enemata  (prepared  from  carbon  dioxide  and  hydro- 
gen sulphide).  I  fancy  that  both  methods,  like  so 
many  other  remedies  for  consumption,  will  be  soon 
forgotten. 


CHAPTER  III. 

SECONDARY    TUBERCULOSIS-COMPLICATIONS 
—LARYNX— INTESTINES— ANAL  FISTUL/E. 

For  the  treatment  of  secondary  tuberculosis  and 
some  complications  which  occur,  I  shall  limit  myself 
to  what  I  have  tested  in  my  private  practice,  used  in 
my  clinics  and  recommended  in  my  consultation  prac- 
tice. 

Pubnonary  hefnorrhage  is  to  be  treated  by  laying 
from  above  downwards  two  ice  bags  on  the  anterior 
chest  wall,  including  the  apices,  and  by  subcutaneous 
injection  of  a  solution  of  sclerotic  acid*  (i.o  gram  to 
5.0  of  distilled  water,  15.4  grs.  to  75  Tl]j),  using  a 
syringeful  every  hour.  The  place  of  the  injection 
should  be  vigorously  kneaded  on  account  of  the  pain, 
or  morphine  may  be  injected.  The  solution  of  sclerotic 
acid  is  much  better  for  subcutaneous  injections  than 
the  solution  of  extract  of  ergot,  which  is  more  painful 
and  may  cause  abscesses.  I  use  the  ergot  for  simul- 
taneous internal  use,  and  continue  it  beyond  the  dura- 
tion of  the  hemorrhage  in  order  to  prevent  relapses 
and  to  quiet  the  anxious  spirits  of  the  patient.  For 
inhalations,  liquor  ferri  sesquichlorati  of  the  strength 
of  2.0  to  200.  (Ti]j  32  to   3  vi-vii)  is  used.     It  is  not 


*  Sclerotic  or  sclerotinic  acid  is  one  of  the  most  active 
constituents  of  ergot.  It  is  a  yellowish  brown,  tasteless,  in- 
odorous substance,  with  a  slight  acid  reaction. — Tr. 


supposed  that  the  nebulized  liquid  reaches  the  bleed- 
ing spot  in  the  pulmonary  tissue  and  acts  there  as  a 
styptic,  but  I  explain  its  excellent  results  by  a  reflex 
contraction  of  the  pulmonary  vessels  being  caused  by 
its  marked  astringent  action  on  the  mucous  membrane 
of  the  upper  air  passages.  Hence  I  only  allow  brief 
inhalations  (one  or  two  minutes),  but  repeated  fre- 
quently, say  every  half  hour.  Morphine,  either  sub- 
cutaneously  or  internally,  is  strongly  recommended 
to  check  the  tendency  to  cough.  Every  cough  tem- 
porarily alters  the  condition  of  the  pulmonary  circula- 
tion, and  the  patient  dreads  to  cough  lest  it  should 
bring  on  another  hemorrhage.  Between  whiles,  I  re- 
quire the  patient  to  take  deep  breaths,  which  help  re- 
markably to  stop  the  bleeding.  As  soon  as  he  has 
overcome  his  dread  of  danger  from  this  deep  inspira- 
tion, I  instruct  him  to  breathe  strongly  for  a  longer 
time.  It  not  seldom  happens  that  this  procedure 
finally  stops  very  obstinate  and  recurring  hemorrhages. 
Tuberculous  ulcers  of  the  larynx,  pharynx^  and 
tongue  can  rarely  be  cured.  Chronic  circumscribed 
laryngeal  ulcers  are  the  most  tractable.  The  exten- 
sive ulcerations  of  the  last  stage  make  the  prognosis 
positively  bad  and  require  only  a  palliative  treatment 
with  anaesthetics,  especially  cocaine  and  the  bromide 
salts.  In  chronic  laryngeal  ulcerations  of  the  early 
stage,  I  am  opposed  to  strong  remedies,  especially  to 
caustics  like  lunar  caustic.  I  recommend  instead  mild 
antiseptics  like  boracic  acid,  potassium  chlorate,  crea- 
sote,  lactic  acid,  or  menthol. 


In  intestinal  tuberculosis,  the  fight  against  the  diar- 
rhoea must  be  incessant.  It  and  the  accompanying 
discomfort  in  the  abdomen  are  best  controlled  by 
opium;  but  for  prolonged  use  the  astringents,  as  tan- 
nic acid,  nitrate  of  silver,  and  especially  the  milder 
astringents,  Colombo,  rhatany  and  kino,  or  the  anti- 
zymotics  as  naphthalin  in  keratin-coated  pills  *  are 
preferable.  Besides,  warm  spiced  wines,  especially 
mulled  wine  and  the  "  berry-wine  "  described  above, 
also  rye  flour  soup  [roggenmehl  suppe)  and  oatmeal 
with  dry  or  moist  warm  applications  to  the  abdomen 
are  recommended. 

A  very  painful  complication  for  the  poor  patient 
is  the  fatal  periproctitis  with  formation  of  complete  or 
incomplete  anal  fistula;.  There  can  be  no  question 
but  that  the  inflammation  of  the  peri-rectal  connective 
tissue  is  due  to  the  tuberculosis,  especially  to  intestinal 
tuberculosis,  for  Schuchardt  and  Krause  have  found 
tubercle  bacilli  in  the  granulations  of  the  fistula,  and, 
even  where  bacilli  were  not  found,  the  infectiousness 
of  the  granulation  tissue  was  proved  by  successful  in- 
oculation m  the  anterior  chamber  of  a  rabbit's  eye. 
On  account  of  the  rarity  of  tuberculous  ulcers  of  the 
rectal  mucous  membrane,   we  must  suppose  that  the 


*  Keratinirten  Plllen.  The  word  refers  to  a  special  coat- 
ing prepared  from  horn  {Kspai).  It  is  not  soluble  in  the  acid 
juice  of  the  stomach,  and  consequently  enables  the  antiseptic 
to  produce  the  desired  effect  in  the  intestines,  in  the  alkaline 
juice  of  which  it  is  soluble. — Tr. 


112    

periproctal  connective  tissues  become  infected  from 
faeces  containing  bacilli  through  some  small  erosion  or 
tear  caused  by  long  retention  of  the  excrement.  It  is 
not  possible  at  present  to  show  that  the  periproctal 
bacillary  process  develops  by  way  of  the  circulation, 
independently  of  changes  in  the  rectal  mucous  mem- 
brane and  analogous  to  the  formation  of  fistulous 
ulcers  in  the  scrofulous.  It  is  much  easier  to  suppose 
an  infection  direct  from  the  contents  of  the  rectal 
cavity — a  view  which  Schuchardt  advocates  in  his 
latest  publications. 

The  success  of  the  radical  treatment  of  such 
fistulse  by  incision,  scraping  or  cautery  is  an  additional 
and  encouraging  evidence  of  the  curability  of  local 
tuberculosis.  It  condemns  in  a  striking  manner  the 
old  teaching  that  they  should  be  left  alone,  because 
after  the  operation  tuberculosis  would  at  once  develop 
in  other  organs.  Tuberculous  rectal  fistulae  should  be 
operated  on  radically  and  as  early  as  possible.  Tuber- 
culosis will  ensue  in  other  parts  just  as  seldom  as  it 
would  after  extirpation  of  tuberculous  glands  or  after 
the  operation  for  a  knee-joint  fungus  in  the  early- 
stages.  ,  I  have  had  under  observation  for  a  long  time 
several  cases  of  chronic  tuberculosis  in  which  fistulae 
were  operated  on  some  years  ago  without  causing  any 
development  of  the  disease. 

The  treatment  of  pulmonary  consumption  covers- 
a  wide  territory  and  I  have  been  able  to  touch  only 
some  of  its  points.      I  would  also  gladly  have  dealt 


—  113  — 

with  tuberculosis  of  the  glands,  serous  membranes, 
brain,  kidneys,  skin,  bones  and  joints,  but  I  must  have 
regard  to  the  size  of  this  book  and  will  defer  them  to 
another  occasion. 

9   KB 


APPENDIX. 

A.     TUBERCULOSIS  IN  AMERICAN   PRISONS. 

In  reply  to  requests,  sometimes  twice  or  thrice 
repeated,  I  received  reports  from  the  penitentiaries 
named    below.     The   figures   bear    out   the   author's 


PENITENTIARIES. 

(„ou- 
victs 
Rec'd 

Total 
Annual 
Popula- 
tion. 

Daily 
Aver- 

Total 
No  of 

U'lnb 
from 
Phthi- 

Per- 
cent- 

during 

age. 

D'ths 

sis. 

age. 

Year. 

California: 

I 

San  Quentin(i888). 

597 

>8i7 

32 

15 

46.8 

2 

Folsom  (iS88). 
Illinois: 

166 

771 

539 

7 

4 

57-1 

3 

Joliet  (i88S>. 

647 

1946 

1321 

45 

35 

77-7 

4 

Chester  (1S87). 

373 

1114 

782 

16 

6 

37-5 

"      (1888). 

344 

1091 

763 

15 

4 

26.6 

Michigan: 

5 

Jackson  (18S6). 
Minnesota: 

293 

1030 

774 

4 

2 

50.0 

6 

Stillwater  (1887). 

208 

59s 

398 

4 

2 

50.0 

(1888). 

214 

626 

426 

4 

I 

25.0 

Missouri: 

7 

Jefferson  City  (1887). 

686 

2321 

20 

5 

25.0 

"     (1888). 

786 

2399 

19 

2 

10  5 

New   York: 

8 

Sinff  Sing  (1887). 

851 

2383 

iS°4 

16 

7 

43-7 

9 

Auburn 

416 

1500 

1146 

32 

17 

531 

lO 

Clinton         " 

Pennsylvania: 

374 

913 

61 2 

6 

4 

66.6 

II 

Eastern  (1887). 

560 

1 691 

27 

21 

77-7 

12 

Allegheny  (1887). 

262 

968 

686 

8 

4 

50.0 

(1888), 

266 

963 

664 

4 

2 

50.0 

Texas: 

I.^ 

Huntsville  (i838). 

28 

9 

32.1 

startling  statements.  The  percentage  of  deaths  from 
phthisis  in  Chicago  during  1887  was  8.77  of  the  total 
mortality.  In  many  of  the  prisons  it  is  from  five  to 
ten  times  higher.  Naturally  the  criminal  classes  are 
more  liable  on  account  of  their  dissipated   and   vaga- 


—  115  — 
bond  lives  to  consumption  and  other  diseases.  But, 
since  tuberculosis  is  in  all  probability  (nay,  certainly) 
contagious,  regard  for  the  welfare  of  society  if  not  for 
the  health  of  the  convicts  should  compel  an  earnest 
effort  to  diminish  or  destroy  the  danger  from  such 
prolific  breeding  places  of  the  disease. 

I.  The  physician  at  San  Quentin  says:  "Whilst  the 
climate  of  Folsom  is  warm  and  dry  and  preeminently  suited  to 
prolong  the  life  of  a  consumptive,  the  moist  climate  of  this 
place  militates  against  and  causes  death  in  a  short  time.  An- 
other thing  is  that  the  men  who  are  sent  here  from  the  southern 
country  are  mostly  Mexicans  and  Indians  and  have  the  germs 
of  scrofula  and  consumption  in  their  blood  on  coming,  which 
soon  develops  itself  and  through  confinement  they  lose  their 
hold  on  life  and  soon  die."  Besides  the  15  prisoners  who 
died  of  phthisis,  6  others  died  of  scrofula. 

2  One  death  at  Folsom  was  from  pneumonia,  and  there 
remained  in  the  hospital  at  the  time  of  the  report  i  patient  with 
phthisis. 

3.  In  Joliet,  there  was  i  death  by  suicide  and  i  from 
pneumonia.  Among  1460  cases  treated  in  the  hospital  during 
that  year,  244  were  for  diseases  of  the  respiratory  system. 

4.  During  2  years,  9  cases  of  phthisis  were  treated  in 
the  Chester  hospital.  In  1887,  there  was  also  i  death  from 
acute  tuberculosis,  i  by  accident  and  i  by  suicide;  in  18S8,  3 
from  pneumonitis,  i  from  tuberculosis  of  mesenteric  glands, 
and  I  by  suicide.  These  two  cases  of  clear  tuberculosis  raise 
the  percentage  to  43  7  and  33  3;  but  for  the  sake  ot  comparison 
I  have  considered  only  "phthisis"  or  "consumption"  in 
the  table.  The  physician  says  very  properly,  in  reference  to 
"the  marked  prevalence  of  tubercular  disease  in  its  varied 
forms,"  that  "had  the  same  people  been  left  to  the  vices, 
excesses  and  deprivations  characteristic  of  their  lives  on  the 


—  ii6  — 

outside  of  prison,  there  is  no  doubt  that  fully  twice  as  many 
would  have  died  of  this  disease  during  the  same  period,  as 
did  here.  The  record  shows  many  of  them  to  have  been 
men  who  had  long  been  confined  in  prison;  others  were  in  an 
advanced  stage  of  the  disease  when  admitted  and  consequently 
could  not  have  lived  long,  in  or  out  of  prison." 

5.  Of  the  prisoners  received  during  the  year  at  Jack- 
son 276  were  in  good  and  17  in  poor  health;  43  had  lost  one 
or  other  parent  by  consumption;  i  death  was  due  to  stabbing. 
The  2  who  died  of  phthisis  had  been  respectively  6  months 
and  25  years  in  prison. 

6.  Among  the  deaths  at  Stillwater  in  1888,  i  was  due 
to  accident,  i  to  suicide,  and  i  to  scrofula.  All  the  pa- 
tients who  died  from  disease  were  diseased  when  they  entered 
the  penitentiary.  The  physician  says:  "  It  may  appear 
strange  that  we  have  so  heavy  a  percentage  of  deaths  from 
consumption,  but  to  successfully  treat  consumption  or  those 
predisposed  to  the  disease  requires  surroundings  that  are  not 
to  be  found  in  an  institution  of  this  kind." 

7.  The  physician  of  the  Jefferson  City  penitentiary  re- 
ports that  in  1887,  he  treated  21  cases  of  phthisis  and  2  of  in- 
testinal tuberculosis,  and  in  1888  i  of  acute  phthisis  and  11  of 
phthisis  pulmonalis.  Among  the  deaths  in  1887  was  i  from 
intestinal  tuberculosis  and  in  1888  i  from  traumatic  pneumonia. 
The  warden's  report  shows  three  deaths  not  noted  by  the  phy- 
sician, viz.,  I  from  apoplexy,  i  "died  in  cell,"  and  i  killed  by 
guard.     The  percentage  of  phthisis  is  surprisingly  low. 

8.  Of  the  851  new  convicts  received  during  the  year  at 
Sing  Sing,  598  were  in  good  health  and  253  were  "partially 
disabled."  The  percentage  of  deaths  on  the  total  number  of 
convicts  is  0.67,  and  on  the  daily  average  1.06.  Of  those 
who  died  of  phthisis  the  shortest  confinement  was  2  months, 
and  the  longest  26  months. 

9.  The  physician  at  Auburn  says:     "  The  mortality  has 


—   117  — 

been  abnormally  large  as  compared  with  former  years. 
Convicts  have  been  transferred  to  this  prison  during  the  past 
year  in  the  last  stages  of  consumption,  who  were  carried  from 
the  cars  to  the  hospital,  unable  to  walk  or  help  themselves 
and  who  died  shortly  afterwards."  There  were  also  3  deaths 
from  scrofula,  i  from  pneumonia,  and  2  by  suicide.  The 
terms  of  imprisonment  of  the  victims  of  phthisis  ranged  from 
3  to  42  months,  being  over  i  year  in  11  cases.  The  previous 
health  of  only  2  is  reported  as  fair,  the  rest  being  poor  or 
very  bad;  the  previous  habits  of  f^  were  temperate,  of  2 
moderate.,  and  of  9  intemperate. 

10.  There  was  also  i  death  from  hemoptysis  at 
Clinton.  The  confinements  were  respectively  3,  25,  31,  and 
43  months. 

11.  Of  all  the  reports  which  I  have  examined,  that  of 
the  Eastern  penitentary  of  Pennsylvania,  situated  at  Phila- 
delphia, is  the  most  interesting.  The  report  of  Dr.  W. 
DufEeld  Robinson,  the  physician  in  charge,  is  complete.  It 
shows  that  of  the  560  convicts  received  during  the  year,  345 
were  in  unimpaired  and  215  in  impaired  physical  health;  59 
were  consumptives;  121  were  from  families  in  which  con- 
sumption was  strongly  hereditary  (313  deaths  from  that  dis- 
ease having  occurred  in  their  immediate  families).  Of  the 
total  convict  population  in  1887  (1691),  126  were  consump- 
tive and  the  average  number  of  these  under  treatment 
was  66.  Of  the  21  who  died  from  consumption,  10  were 
unable  to  give  a  reliable  family  health  history,  and  11 
gave  a  family  history  of  consumption.  All  but  2  of  the 
21  were  afflicted  with  the  disease  on  their  admission,  their 
health  being  rated  as:  bad  11,  poor  i,  impaired  4,  and  fair  5 
The  length  of  confinement  ranged  from  4  to  90  months,  most 
of  the  cases  being  between  i  and  2  years.  There  was  i 
death  by  suicide.  Dr.  Robinson  says:  "  In  those  convicts 
in    whom    it  is  found    on    reception    that    there  is    a   strong 


—  ii8  — 

hereditary  tendency  to  consumption  or  that  it  already  exists, 
appropriate  care  to  prevent  its  development  or  progress  is 
taken  by  securing  for  the  convict  appropriate  work,  medica- 
tion, and  special  gymnastic  exercises  for  the  benefit  of  the 
lungs."  He  justly  says:  "With  the  exception  of  the  simple 
treatment  of  disease  the  work  of  the  medical  officer  of  the 
penitentiary  is  of  so  distinct  a  character  and  requires  such 
special  study  and  experience  to  secure  accuracy  in  his  inter- 
view and  investigation  work  as  to  be  almost  a  distinct  pro- 
fession." This  penitentiary  is  the  only  one  in  the  United 
States  conducted  on  the  cellular  or  solitary  system.  What- 
ever may  be  said  in  behalf  of  that  system  from  a  monetary 
or  disciplinary  standpoint,  the  fearful  ratio  of  mortality  from 
phthisis  would  indicate  that  it  is  not  to  be  recommended  from 
a  sanitary  point  of  view. 

12.  The  total  cases  of  phthisis  treated  in  the  hospital  at 
Alleghany  during  1887  were  14,  of  whom  5  were  returned  to 
cell,  2  discharged  from  prison  and  3  remained  sick.  During 
1888,  thev  were  19,  15  being  returned  to  cell  and  2  remaining 
sick.  In  1887,  there  was  i  death  from  hemoptysis.  Those 
who  died  from  phthisis  had  been  confined  respectively  32,  64,  3. 
30,  49  and  61  months.  The  physician  says:  "  It  would  seem 
that  the  regularity  of  prison  treatment  seems  to  prolong  life 
when  suffering  from  a  pronounced  type  of  disease." 

13.     There  are  8  convicts  now  in  Huntsville  prison  with 
symptoms  of  phthisis. 


B.     HOW  TO   LOOK  FOR  TUBERCLE  BACILLI   IN 
SPUTUM, 

The  following  procedure,  which  I  have  translated 
from  Kunze's  Grundriss  der  Praktischen  Median,  is 
Ehrlich's  method  somewhat  modified: 

Press  a  little  of  the  suspected  sputum  between 
two  cover-glasses  so  as  to  get  a  very  thin  layer.  Dry 
the  cover-glasses  separately,  either  by  moving  them 
through  the  air  or  holding  over  a  flame,  or  by  passing 
a  few  times  through  the  flame.  This  fixes  and  dries 
the  preparation.  Place  some  drops  of  aniline  oil  in  a 
reagent  glass  half  filled  with  water,  shake,  and  filter 
into  a  watch  glass.  Add  several  drops  of  an  alcoholic 
solution  of  fuchsin  or  methyl  violet  to  the  contents  of 
the  watch  glass  till  they  are  markedly  colored.  Warm 
this  mixture  till  it  begins  to  smoke.  Place  the  cover- 
glass  with  the  dried  sputum,  face  downwards,  on  the 
warm  liquid  and  let  it  float  for  from  three  to  five  min- 
utes. Remove  and  rinse  in  alcohol,  acidulated  with 
nitric  or  hydrochloric  acid,  until  very  slight  traces  of 
color  remain;  then  rinse  in  ordinary  alcohol  (70  or  80 
per  centj.  Dry  the  cover-glass  as  before  by  holding 
above  a  flame,  clean  it  where  necessary,  add  a  little 
pure  glycerin,  and  set  under  the  microscope.  An  en- 
largement of  400  diameters  will  show  the  bacilli  if 
present. 


HtEMATIC 
HYPOPHOSPHITES, 


DARKE,    DAVIS   &   COMPANY   invite  attention   to  their  prepara- 
tion   of   hypophosphites. 

In  the  debilitated  conditions  in  which  the  preparations  of  the 
hypophosphites  are  usually  prescribed,  minute  doses  often  exert 
a  more  favorable  influence  than  the  large  dose  which  the  physician 
is   tempted   to   prescribe. 

In  cases  of  nervous  exhaustion  especially,  recuperation  is  neces- 
sarily slow,  and  medication  to  be  successful  must  be  based  on  the 
maxim,  festina   lente. 

This  combination  of  remedies  is  one  adapted  to  a  great  variety 
of  diseased  conditions.  It  is  likely  to  prove  useful  wherever  there 
is  debility  or  depraved  nutrition,  but  it  is  especially  appropriate 
in  cases  of  anaemia  and  nervous  prostration,  in  consumption,  and 
in    scrofulous    and    tubercular   affections. 

The  advantages  of  this  preparation  over  others  of  a  similar 
nature  in  the  market  are  its  greater  purity,  assimilability,  medic- 
inal efBcacy,  nutritiousness,  and  the  additional  fact  that  it  is  not 
a  proprietary  product.  Its  careful  comparison  by  physicians  with 
all  other  preparations  of  hypophosphites  is  solicited  in  the  belief 
that   such   a   test   cannot   fail   to   demonstrate   its   superiority. 


PARKE,   DAVIS   &   COMPANY, 

DETROIT  AND  NEW  YORK. 


PHYSICIAN'S  LEISURE  LIBRARY 


PRICE !  PAPER,  25  CTS.  PER  COPY,  $2,50  PER  SET  i  CLOTH,  50  GTS.  PER  COPY, 
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SERIES  I. 


Inhalersi  Inhalations  and  Innalants. 
By  Beverley  Robinson,  M.  D. 

The  Use  of  Electricity  in  the  Removal  of 
Superfluous  Hair  and  the  Treatment  of 
Various  Facial  Blemishes.    ^ 
By  Geo.  Henry  Fox,  M.  D. 

New  Medications.  _, 

By  Dujardin-Beaumetz,  M.  D. 

The  Modern  Treatment  of  Ear  Diseases. 
By  Samuel  Sexton,  M.  D. 

Spinal  Irritation.,    ^^  ,    »,    t.^ 

By  William  A  Hammond,  M.  D. 

The  Modern  Treatment  of  Eczema. 
By  Henry  G.  Piffard,  M.  D. 


Antiseptic  Midwifery.  , 

By  Henry  J.  Garrigues,  M    D. 

On  the  Determination  of  the  Necessity  fo 
Wearing  Glasses.  „ 

By  D7B.  St.  John  Roosa,  M.  D. 

The  Physiological, Pathologica'l  and  Ther- 
apeutic Effects  of  Compressed  Air. 

By  Andrew  H.  Smith,  M.  D. 
GranularLidsandContagiousOphthalmia. 

By  W.  F.  Mittendoif,  M.  D. 
Practical  Bacteriology. 

By  Thomas  E.  Saiterthviraite,  M.  D, 
Pregnancy,  Parturition  and  the  Puerperal 
State  and  their  Complications. 

By  Paul  F.  Munde,  M.  D. 


SERIES  II. 


The  Diagnosisand  Treatment  of  Haemor- 
rhoids. ,,  ,         ,,   T.^ 
By  Chas.  B.  Kelsey,  M   D. 

Diseases  of  the  Heart.    Vol.1. 

By  Dujardin-Beaumetz,  M.  D. 

Diseases  of  the  Heart.    Vol.11. 

By  Dujardin-Beaumetz,  M    D. 

The  Modern  Treatment  of  Diarrhoea  and 
Dysentery.  ,,    „ 

By  A.   B.   Palmer,  M.   D. 

Intestinal  Diseases  of  Children. 
By  A.  Jacobi,  M.  D. 


The  Modern  Treatment  of  Headaches. 
By  Allan  McLane  Hamilton,   M.  D. 

The  Modern  Tieatment  of  Pleurisy  and 
Pneumonia. 

By  G.  M.  Garland,  M.  D 
How  to  Use  the  Laryngoscope.    . 

By  an  Eminent  Laryngologist. 
Diseases  of  the  Male  Urethra. 

By  Fessendea  N.  Otis,  M.  D. 
The  Disorders  of  Menstruation. 

By  Edward  W.   Jenks,   iM.  D. 
The  Infectious  Diseases.  In  2  vols. 

By  Karl    Liebermeisier. 


SERIES  III. 


Abdominal   Surgery 

By  Hal  C.  Wyman,  M.  D. 

Diseasesof  the  Liver. 

By  Dujardin-Beaumetz,  M.  D. 

Hysteria  and  Epilepsy.    .        ^^    ^ 
By  J.  Leonard  Corning-,  M.  D. 

Diseases  of  the  Kidney. 

By  Dujardin-Beaumetz,  M.  D. 

The  Theory  and  Practice  of  the  Ophthal- 
moscope. 

By  J.  Herbert  Claiborne,  Jr..  M.  D. 
Modern  Treatment  of  Bright's  Disease. 

By  Alfred   L.    Loomis,    M.  D. 
Clinical  Lectures  on  Certain  Diseases  of 
Nervous  System. 

By  Prof.  J.  M.  Charcot,  M.  D. 


The  Radical  Cure  of  Hernia. 

By  Henry  O.   Marcy,   A.  M.,  M.  D., 
L.  L.  D. 

The  Treatment  of  Diseases  of  the  Blad- 
der, Prostate  and  Urethra. 
By  H.  O.  Walker,  M.  D. 

Dyspepsia. 

By  Frank  Woodbury,  M.  D. 

The  Treatment  of  the  Morphia  Habit. 
By  Erlenmeyer. 

The  Etiologly,  Diagnosisand  Therapy  of 
Tuberculosis. 

By  Prof.  H.  von  Ziemssen. 


GEORGE  S.  DAVIS,  Publisher, 


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Ziemssen 


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1588 


Pulmonary'-  tuberculosis. 


■Mll4t£§?         <^.  1^.  BINMny 


^^^^t 


